The nurse is completing a focused assessment addressing a patient's immune function. What should the nurse prioritize in the physical assessment?
A) Percussion of the patient's abdomen
B) Palpation of the patient's liver
C) Auscultation of the patient's apical heart rate
D) Palpation of the patient's lymph nodes
Ans: D
Feedback:
During the assessment of immune function, the anterior and posterior cervical, supraclavicular, axillary, and inguinal lymph nodes are palpated for enlargement. If palpable nodes are detected, their location, size, consistency, and reports of tenderness on palpation are noted. Because of the central role of lymph nodes in the immune system, they are prioritized over the heart, liver, and abdomen, even though these would be assessed.
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