Nokea
The nurse is caring for a client with Hodgkin's disease who has developed anemia. What would the nurse expect to be prescribed for this client?
- A. Lower doses of radiation
- B. Transfusions
- C. A break in chemotherapy
- D. Increased rest and fluid
Correct Answer: B
Rationale: Transfusions are prescribed to control anemia. If resistance to treatment develops, autologous bone marrow or peripheral stem cells are harvested, followed by high doses of chemotherapy that destroy the bone marrow. A transplant is performed after separating the normal stem cells from the malignant cells in the harvested specimen. Lower doses of radiation, breaks in chemotherapy, and increased rest and fluid are not considered part of the treatment regimen for anemia.
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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.
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.
A client with lymphedema in the left arm has weeping from the skin and has a small 2-cm ulcer on the upper arm. What test does the nurse anticipate the client will be prepared for?
- A. X-ray of the left arm
- B. Ultrasound of the left arm
- C. CT scan
- D. Lymphangiography
Correct Answer: D
Rationale: Lymphangiography is a special examination in which an intravenous dye and radiography are used to detect lymph node involvement that reveals the degree and extent of blockage in the lymph system. An x-ray of the arm, ultrasound, or CT scan will not reveal the extent of blockage.
The nurse is obtaining objective data from a client with lymphangitis of the left arm. What does the nurse expect to find when collecting this data from the client?
- A. Pulsatile mass in the axilla
- B. Weeping and oozing of fluid from the arm
- C. Cold, clammy arm
- D. Red streaks following the course of the lymph channels
Correct Answer: D
Rationale: Red streaks follow the course of the lymph channels and extend up the arm or leg. Fever also may be present. When lymphadenitis is present, the lymph nodes along the lymphatic channels are enlarged and tender on palpation. Diagnosis is made by visual inspection and palpation. The nurse does not expect to find a pulsatile mass. Weeping and oozing would indicate lymphedema. The arm would be warm or hot, not cold and clammy.
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.