Question

The nurse is completing a focused assessment addressing a client's immune function. What should the nurse prioritize in the physical assessment?

a. Percussion of the client's abdomen
b. Auscultation of the client's apical heart rate
c. Palpation of the client's liver
d. Palpation of the client's lymph nodes

Answer 1

Answer is D
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.)