The nurse is performing an assessment on a healthy preschool-age client and palpates two enlarged lymph nodes on the child's neck. The lymph nodes are soft, mobile, nontender, and each is less than 1 cm in diameter
Which action by the nurse is the most appropriate?
1. Assess for an infected wound.
2. Document this as a normal finding.
3. Notify the healthcare provider.
4. Obtain an order for a throat culture.
Correct Answer: 2
It is a normal finding to determine that a child has several enlarged lymph nodes less than 1cm such as these. When lymph nodes are significantly enlarged, greater than 1cm, the nurse should assess the child for an infection. Documenting this as a normal finding is appropriate since these enlarged lymph nodes are small, less than 1cm, nontender, and mobile. It is not necessary for the nurse to notify the healthcare provider at this time. Obtaining an order for a throat culture would be an appropriate nursing action if the child had significantly enlarged lymph nodes and evidence that an infection was present in the child's pharynx.
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