The nurse is performing an assessment of the client's head and neck. The client requests information about the assessment of her lymph nodes. Which of the following is the best response?
1. "Sometimes, enlarged lymph nodes indicate an infection.".
2. "All of your lymph nodes should be easily palpable.".
3. "The lymph system makes antibiotics to treat infection.".
4. "When one lymph node is identified as being enlarged, this is always an abnormal finding.".
1
Rationale 1: The lymph nodes are part of the lymphatic system and provide the body with protection against infection. It is true that sometimes when the nurse is able to palpate enlarged lymph nodes this indicates that the client has developed an infection.
Rationale 2: Lymph nodes should not be palpable.
Rationale 3: The lymph system does not make antibiotics; it makes antibodies and lymphocytes to protect the client from infection.
Rationale 4: It is not necessarily abnormal to be able to palpate one enlarged lymph node.
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