The nurse is performing an assessment on a healthy 5 year old 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
The nurse would choose which of the following actions in this situation? 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.
2
Rationale 1: It is a normal finding to determine that a child has several enlarged lymph nodes such as these. When lymph nodes are significantly enlarged, the nurse should assess the child for an infection.
Rationale 2: This is appropriate since these enlarged lymph nodes are small, nontender, and mobile.
Rationale 3: t is not necessary for the nurse to notify the healthcare provider at this time.
Rationale 4: This 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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