Nokea
The client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client experiences nausea. What measures should the nurse suggest to help the client reduce the feeling of nausea?
- A. Administer immunosuppressive drugs.
- B. Apply ice to the skin for brief periods.
- C. Offer clear liquids such as carbonated beverages, water, and ice pops.
- D. Advise bed rest as much as possible.
Correct Answer: C
Rationale: To help reduce the feeling of nausea in a client who underwent chemotherapy, the nurse should offer clear liquids such as carbonated beverages, water, ice pops, and gelatin until the nausea subsides. Immunosuppressive drugs are known to cause non-Hodgkin's lymphoma when administered to prevent a transplant rejection. These drugs do not help in reducing the feeling of nausea. The nurse may need to apply ice to the skin to prevent it from itching and thereby promote the skin integrity. Bed rest, analgesic and antipyretic therapy, and increased fluid intake are recommended to clients with infectious mononucleosis.
You may also like to solve these questions
Which client does the nurse recognize as most likely to be diagnosed with non-Hodgkin's lymphoma rather than Hodgkin's lymphoma?
- A. A 55-year-old client with an immunosuppression disorder
- B. A 35-year-old client with type 2 diabetes mellitus
- C. A 20-year-old client with infectious mononucleosis
- D. A 40-year-old client with Reed-Sternberg cells in an axillary lymph node
Correct Answer: A
Rationale: Non-Hodgkin's lymphoma peak onset is after 50 years and is common among clients with immune suppression. There is no correlation with client that has diabetes and non-Hodgkin's lymphoma. Forty percent of affected clients test positive for Epstein-Barr virus that causes infectious mononucleosis and that test positive for Reed-Sternberg cells in the lymph nodes that are correlated with Hodgkin's lymphoma.
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 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 performing a physical assessment on a client with a suspected lymphatic disorder. What would be the nurse's primary assessment for all clients with lymphatic disorders?
- A. Fever and sore throat
- B. Painful joints
- C. Signs of leukopenia and thrombocytopenia
- D. Enlargement of the lymph glands
Correct Answer: D
Rationale: Most of the disorders related to the lymph glands cause an inflammation of the lymph nodes. As a result, the nurse should assess the extent of enlargement of the lymph glands in a client suspected of a lymphatic disorder. Fever and sore throat are the secondary signs and symptoms in such disorders. These clients do not complain of painful joints or exhibit signs of leukopenia and thrombocytopenia.
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.