Nokea
An adult client has developed lymphedema postmastectomy. What is the common method used to promote lymphatic drainage and prevent edema in all clients with lymphedema?
- A. Reduce the intake of fluids.
- B. Avoid exercising the affected part.
- C. Decrease the intake of sodium and calcium.
- D. Elevate the affected part of the body.
Correct Answer: D
Rationale: Treatment usually is symptomatic. In the early stages, the client elevates the affected part to promote lymphatic drainage. Exercising the affected part in the client helps in promoting the lymphatic circulation and maintaining the functional use of the limb. Reducing the sodium and calcium intake or fluids does not promote lymphatic drainage or prevent edema.
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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.
A client with Hodgkin's disease has a weight loss of 10% of body weight 6 months prior to the diagnosis, fever of 101?°F, and drenching night sweats. What sub classification of Hodgkin's disease does this client fit into?
- A. A
- B. B
- C. C
- D. D
Correct Answer: B
Rationale: Stages I, II, III, and IV of adult Hodgkin's disease are subclassified into A and B categories: B for those with defined general symptoms and A for those without B symptoms. The B designation is given to client with any of the following symptoms: unexplained loss of more than 10% of body weight in 6 months before diagnosis, unexplained fever with temperatures over 100.4?°F, and drenching night sweats. There is no sub classification of C or D.
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).
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 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.