Nokea
A client with lymphedema of the left leg has a nursing diagnosis of Altered Body Image Perception related to lymphedema of the left leg as evidenced by the statement, 'I look terrible and am embarrassed to go out.' What intervention can the nurse provide to help this client?
- A. Inform the client it is acceptable to stay away from social activities.
- B. Encourage the client to go out and socialize despite not wanting to
- C. Suggest certain styles of clothing that conceal the enlargement of the leg.
- D. Refer the client to a psychiatrist.
Correct Answer: C
Rationale: Extensive emotional support is necessary when the edema is severe. The client's self-esteem often is decreased, which can lead to social withdrawal. The nurse supports the client's self-image by suggesting certain styles of clothing that conceal abnormal enlargement of an arm or leg. Informing the client to stay away from social activities can create a depressed mood and loneliness. The client should not be encouraged to go out and socialize if not ready nor referred to a psychiatrist at this point.
You may also like to solve these questions
A client with Hodgkin's disease has bilateral lymph nodes that are affected with extension through the spleen as well as affecting the bone marrow. What stage of the disease does the nurse recognize the client is in?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage IV involves bilateral lymph nodes affected and extension includes spleen plus one or more of the following: bones, bone marrow, lungs, liver, skin, gastrointestinal structures, or other sites. Stage I is single lymph node region. Stage II is two or more lymph node regions on one side of the diaphragm. Stage III is lymph node regions on both sides of the diaphragm, but extension is limited to the spleen.
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.
The nurse is providing instruction on the use of compression garments for the client with lymphedema. What should be included in the instructions? Select all that apply.
- A. Purchase two compression garments.
- B. Change the garment in the morning and in the evening.
- C. Limit the time the garment is not worn to 30 to 60 minutes.
- D. Replace a compression garment every month.
- E. Place the garment in the dryer after washing
Correct Answer: A,B,C
Rationale: When instructing the client on use of the compression garment, purchase two compression garments so that one can be worn while the other is washed and dried. Change the garment in the morning and again in the evening because the garment becomes stretched after 12 hours of being worn. Limit the time that the garment is not worn to no more than 30 to 60 minutes to prevent re accumulation of tissue fluid and stretched skin. The garment should be replaced every 4 to 6 months, not every month. The garment should be air dried, not placed in the dryer.
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.
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.