Nokea
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.
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The nurse is caring for a group of clients. Which client does the nurse suspect is most likely to have mononucleosis?
- A. A 46-year-old who is complaining of chest pain and weakness
- B. A 19-year-old college student with cervical node enlargement and fever
- C. A 28-year-old with lower abdominal discomfort and vaginal discharge
- D. A 30-year-old with a cough, chest discomfort, and fever
Correct Answer: B
Rationale: The virus most commonly affects young adults, especially those in close living quarters, such as armed services housing and college dormitories. Fatigue, fever, sore throat, headache, and cervical lymph node enlargement typically occur. The tonsils ooze white or greenish-gray exudates. Pharyngeal swelling can compromise swallowing and breathing. Some clients develop a faint red rash on their hands or abdomen. The liver and spleen become enlarged. The other clients with presenting symptoms do not correlate with the symptoms of mononucleosis.
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 on a mission trip to a third world country to provide nursing care to a large group of clients. A client asks the nurse to look at his leg that is grossly edematous compared to the other extremity. What does the nurse understand is the most common cause of this disorder known as elephantiasis?
- A. Reaction to an antibiotic
- B. Smallpox vaccination
- C. Lack of healthcare
- D. A parasitic worm
Correct Answer: D
Rationale: Worldwide, the most common cause of lymphedema is a parasitic worm; mosquitoes transmit the parasite, resulting in a condition known as elephantiasis.
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 collecting objective data from the client with lymphedema of the left leg. The nurse observes that the affected leg is 10 cm greater in measurement than the unaffected leg. The affected leg is hot to the touch and red. What classification of lymphedema does the nurse recognize this client has?
- A. Grade I (Mild)
- B. Grade II (Moderate)
- C. Grade III (Severe)
- D. Grade IV (Extreme)
Correct Answer: C
Rationale: In 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 (inflammation of connective tissue in or close to the skin). Mild is the circumference of the limb is 2 cm, but not more than 4 cm larger than the unaffected limb; client is asymptomatic. Moderate lymphedema is the circumference of the 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. There is no classification considered extreme.