Nokea
A teenaged client arrives at the clinic and reports having attended 2 weeks of summer camp last month and now is not feeling well with complaints of sore throat, fever, and feeling very tired. The nurse observes white exudate on the tonsils. What test does the nurse anticipate the physician will order for this client?
- A. Monospot test
- B. AST and ALT
- C. Glucose level
- D. T3, T4, and TSH
Correct Answer: A
Rationale: A positive slide agglutination test (Monospot, Monotest, Monosticon) is presumptive evidence that the Epstein-Barr virus is causing the symptoms. A rise in the Epstein-Barr virus antibody titer and a heterophil agglutination test result of 1:224 or greater is conclusive for infectious mononucleosis. The AST and ALT would indicate possible liver disorders. A glucose level would not be indicative of Epstein-Barr virus. T3, T4, and TSH would be indicative of thyroid dysfunction, which the client's age and symptoms do not correlate with.
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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.
A young client has just been diagnosed with lymphoma. The client asks the nurse what a lymphoma is. What would be the nurse's best answer?
- A. It is a group of cancers that affect the body.
- B. It is a group of cancers connected to the hematopoietic system.
- C. It is a group of cancers that affect the lymphatic system.
- D. It is a group of cancers connected to the cardiovascular system.
Correct Answer: C
Rationale: The term lymphoma applies to a group of cancers that affect the lymphatic system. The correct option is more specific than the option of 'a group of cancers that affect the body.' Lymphomas are not related to the hematopoietic or cardiovascular systems.
The nurse is caring for a client with lymphedema of the left arm in the clinic. The nurse measures a circumference of the affected extremity 4 cm larger in circumference than the opposite limb, and the client complains of feeling a heaviness and pain. There is limited movement of the left arm. What would the nurse grade and document this lymphedema as?
- A. Grade I (Mild)
- B. Grade II (Moderate)
- C. Grade III (Severe)
- D. Grade IV (Grossly edematous)
Correct Answer: C
Rationale: Grade II (Moderate), the circumference of affected limb is 4 cm, but not more than 8 cm larger than the unaffected limb; client experiences symptoms such as heaviness in the limb, pain, and limited movement. In Grade I (Mild), the circumference of the affected limb is 2 cm, but not more than 4 cm larger than the unaffected limb; the client is asymptomatic. In Grade III (Severe), the circumference of the affected limb is 8 cm greater than the unaffected limb, involves the entire limb, or is accompanied by infection or cellulitis. There is no Grade IV.
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.
A client has developed an infection that resulted in lymphangitis. What does the nurse suspect the causative organism is that caused the infection?
- A. A streptococcal microorganism
- B. A Staphylococcus microorganism
- C. Escherichia coli
- D. Candida albicans
Correct Answer: A
Rationale: An infectious agent, commonly a streptococcal microorganism, usually causes both lymphangitis and lymphadenitis. It is not commonly caused by staph, E. coli, or C. albicans (a fungal infection).