The clinic nurse is assessing a teenage girl who reports fever, chills, sore throat, and extreme fatigue during the last 2 weeks. Which focused assessment should the nurse perform?
A.
Assess lymph nodes.
B.
Collect buccal swabs.
C.
Obtain a urinalysis.
D.
Palpate the abdomen.
ANS: A
This girl's age and symptoms are highly suggestive of infectious mononucleosis. The nurse should assess for swollen and tender occipital and cervical lymph nodes. The nurse should not palpate the abdomen because the spleen, if enlarged, can rupture under pressure. Buccal swabs and urinalysis are not related.
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