Nokea
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.
You may also like to solve these questions
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.
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.
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.
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.
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.