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    HESI RN health assessment proctored exam

    The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

    Explanation & Rationale

    A. Record this normal finding in the assessment record: An enlarged lymph node is not a normal finding and should not be recorded as such. It may indicate an infection, inflammation, or other underlying conditions. Further investigation is required to determine the cause of the enlargement.B. Ask the client about any localized tenderness at the site: Assessing tenderness in the enlarged lymph node helps the nurse gather information about the potential cause. Tender lymph nodes are often associated with infections or inflammation, while non-tender nodes may indicate other issues, such as malignancy. This assessment is crucial in guiding further action.C. Auscultate the lymph node for the presence of a bruit: A bruit is an abnormal sound that indicates turbulent blood flow and is typically heard over arteries, not lymph nodes. Auscultating a lymph node for a bruit is not relevant to this assessment.D. Cover the inflamed area and notify the healthcare provider: While notifying the healthcare provider may be necessary later, the immediate priority is to assess the lymph node's characteristics, including tenderness and any other related symptoms, to guide appropriate action. Simply covering the area without further assessment would delay the necessary evaluation.

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