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A client comes to the clinic and informs the nurse of swelling in right arm. There has been no injury or precipitating occurrence that caused the swelling. The nurse observes nonpitting edema from the upper arm to the fingertips. What action should the nurse initially perform?
- A. Instruct the client to elevate the extremity.
- B. Inspect and measure the arm.
- C. Apply a compression stocking.
- D. Administer a diuretic.
Correct Answer: B
Rationale: The nurse inspects and measures the affected area to assess the extent of enlargement and the condition of the skin initially. After collecting the data, the nurse may instruct the client to elevate the arm and obtain the correct size for a compression stocking. Diuretic use is not an appropriate intervention at this time and would not be administered without a physician's prescription.
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An adolescent client diagnosed with infectious mononucleosis asks the nurse if it is possible to keep getting the disease in the future. What is the best response by the nurse?
- A. After having the disease, the virus dissipates and is gone forever.'
- B. Once you get the virus, it will infect you when your immune system is compromised.'
- C. One episode produces immunity, but the virus remains for a lifetime.'
- D. Once you have the symptoms of the virus, it will go away within a week and there will be no further episodes.'
Correct Answer: C
Rationale: One episode of infectious mononucleosis produces subsequent immunity; however, the virus remains in the body for the person's lifetime. The virus does not dissipate and go away. If a client has an incidence of infection, the client is immune from further infections of Epstein-Barr virus. The symptoms do not generally go away for 2 to 6 weeks.
A client with non-Hodgkin's lymphoma is receiving chemotherapy for treatment. The client is complaining of nausea during treatment. To maintain fluid intake, what type of food or fluid could the nurse offer the client?
- A. Milk
- B. Pudding
- C. Popsicle
- D. Chicken
Correct Answer: C
Rationale: Offer clear liquids such as carbonated beverages and water, ice pops, and flavored gelatin until nausea subsides. Thereafter, small, frequent, low-fat meals help prevent nausea, improve nutritional intake, and reduce weight loss. Milk, pudding, and chicken are too heavy when clients are experiencing nausea and may be given after the nausea subsides.
The nurse is caring for a client with lymphangitis of the right leg who is receiving treatment with a broad-spectrum antibiotic. The nurse is giving a bath and observes the right leg is larger than it was 2 hours ago, and the client feels hot. What is the first action by the nurse?
- A. Place the leg below the level of the heart.
- B. Notify the physician.
- C. Place cool compresses on the extremity.
- D. Begin performing passive range of motion exercises.
Correct Answer: B
Rationale: The nurse notifies the physician if the affected area appears to enlarge, additional lymph nodes become involved, or body temperature remains elevated. In severe cases with persistent swelling, the nurse teaches the client how to apply an elastic sleeve or stocking. The leg should be elevated to reduce the edema. A warm compress may be applied to promote comfort and enhance circulation. Passive range of motion would be contraindicated at this time.
A client had a left radical mastectomy with an axillary node dissection 6 months ago and is having a large amount of edema in the left arm down to the fingers. What should the nurse inform the client is the reason for the edema?
- A. An accumulation of lymphatic fluid that results from impaired lymph circulation.
- B. It is congenitally acquired and is not related to the mastectomy.
- C. They are most likely ingesting too much sodium and should be advised to decrease the amount.
- D. There is inadequate blood flow from circulatory impairment.
Correct Answer: A
Rationale: Lymphedema is an accumulation of lymphatic fluid that results from impaired lymph circulation. It is a complication resulting from the removal of multiple lymph nodes at the time of mastectomy or radiation for cancer. It may be congenitally acquired, but in this situation, it is secondary and related to the mastectomy. Sodium intake would not be related to the accumulation of lymph fluid and would be generalized. There is not circulatory impairment from decreased blood flow but impaired lymphatic flow.
The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake?
- A. Eat warm food and drink warm liquids.
- B. Eat soft, bland foods and drink cool liquids.
- C. Avoid spicy foods and drink warm liquids.
- D. Eat soft, bland foods and drink warm liquids.
Correct Answer: B
Rationale: The nurse inspects the client's throat for the extent of inflammation or edema. He or she gently palpates the lymph nodes to detect swelling and encourages fluids. Soft, bland foods and cool liquids are best for clients with ulcerations of the oral mucosa. Warm food and liquids and spicy food are not recommended.