Nokea
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.
You may also like to solve these questions
A client with Hodgkin's disease has bilateral lymph nodes that are affected with extension through the spleen as well as affecting the bone marrow. What stage of the disease does the nurse recognize the client is in?
- A. I
- B. II
- C. III
- D. IV
Correct Answer: D
Rationale: Stage IV involves bilateral lymph nodes affected and extension includes spleen plus one or more of the following: bones, bone marrow, lungs, liver, skin, gastrointestinal structures, or other sites. Stage I is single lymph node region. Stage II is two or more lymph node regions on one side of the diaphragm. Stage III is lymph node regions on both sides of the diaphragm, but extension is limited to the spleen.
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.
A client with lymphedema of the left leg has a nursing diagnosis of Altered Body Image Perception related to lymphedema of the left leg as evidenced by the statement, 'I look terrible and am embarrassed to go out.' What intervention can the nurse provide to help this client?
- A. Inform the client it is acceptable to stay away from social activities.
- B. Encourage the client to go out and socialize despite not wanting to
- C. Suggest certain styles of clothing that conceal the enlargement of the leg.
- D. Refer the client to a psychiatrist.
Correct Answer: C
Rationale: Extensive emotional support is necessary when the edema is severe. The client's self-esteem often is decreased, which can lead to social withdrawal. The nurse supports the client's self-image by suggesting certain styles of clothing that conceal abnormal enlargement of an arm or leg. Informing the client to stay away from social activities can create a depressed mood and loneliness. The client should not be encouraged to go out and socialize if not ready nor referred to a psychiatrist at this point.
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.
The nurse is sending a client to be fitted for a compression garment for the treatment of lymphedema after having a mastectomy and node dissection. What does the nurse inform the client the garment will do to decrease the edema? Select all that apply.
- A. Increases local tissue pressure
- B. Reduces edema permanently if worn for 30 days
- C. Decreases the stretching of the skin
- D. Helps muscles to propel lymphatic drainage
- E. Prevents tissue refilling with an excess volume of lymph
Correct Answer: A,C,D,E
Rationale: A compression garment, which consists of multiple layers of elastic material with proximal to distal compression gradation, increases local tissue pressure, decreases stretching of the skin, assists muscles to propel lymphatic drainage, and prevents tissue refilling with an excess volume of lymph. Because the lymph nodes have been removed, the condition will not be able to be permanently reduced by using the garment.