Nokea
The nurse is caring for a client newly admitted to the unit with a diagnosis of lymphangitis. What intervention(s) would the nurse institute to help promote the resolution of the lymphangitis? Select all that apply.
- A. Apply ice to the area.
- B. Note the response to antibiotic therapy
- C. Encourage independent activities of daily living.
- D. Elevate the area.
- E. Apply warm soaks/compresses to the area.
Correct Answer: B,C,D,E
Rationale: The nurse inspects the area two to three times daily and notes the client's response to antibiotic therapy, giving assistance if the discomfort interferes with activities of daily living. Elevation reduces the swelling. Warmth promotes comfort and enhances circulation. 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.
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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 caring for a client in the hospital who is being treated for Hodgkin's disease and is taking a chemotherapeutic regimen in the hospital's oncology unit. When reviewing the client's medication history, what regimen does the nurse recognize as the drugs in the treatment of Hodgkin's disease?
- A. Ceftriaxone, furosemide, rifampin, ibuprofen
- B. Doxorubicin, bleomycin, vinblastine, dacarbarine
- C. Albuterol, ipratropium, methylprednisolone, acetylcysteine
- D. Enalapril, atenolol, verapamil, lovastatin
Correct Answer: B
Rationale: Doxorubicin, bleomycin, vinblastine, and dacarbarine are a combination of medications for the chemotherapeutic treatment of Hodgkin's disease. There are several different regimens that may be used but the medications in the other options are not used for the treatment of Hodgkin's disease.
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.
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 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.