The mother of a 7-year-old child states, "I'm concerned because I can feel a few lumps at the base of his neck.". The nurse notes slightly enlarged, firm, nontender, cervical lymph nodes. The lymph nodes are easily moveable under the skin
Which of the following interventions would be appropriate? 1. Speak with the physician about acquiring a throat culture.
2. Assess the client's temperature.
3. Examine the child's tonsils for tonsillitis.
4. Explain to the mother that this is a normal finding.
4
Rationale 1: The client is not exhibiting any clinical manifestations associated with pharyngitis, so a throat culture is not warranted.
Rationale 2: The client is not exhibiting any clinical manifestations of an infection that would result in hyperthermia.
Rationale 3: The client is not exhibiting any clinical manifestations of tonsillitis.
Rationale 4: "Shotty" lymph nodes are a normal variant in preschool and school-age children, and are noninfected, nontender, enlarged nodes that move when palpated.
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