Nokea
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.
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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 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.
An adult client has developed lymphedema postmastectomy. What is the common method used to promote lymphatic drainage and prevent edema in all clients with lymphedema?
- A. Reduce the intake of fluids.
- B. Avoid exercising the affected part.
- C. Decrease the intake of sodium and calcium.
- D. Elevate the affected part of the body.
Correct Answer: D
Rationale: Treatment usually is symptomatic. In the early stages, the client elevates the affected part to promote lymphatic drainage. Exercising the affected part in the client helps in promoting the lymphatic circulation and maintaining the functional use of the limb. Reducing the sodium and calcium intake or fluids does not promote lymphatic drainage or prevent edema.
A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?
- A. How to apply an elastic sleeve or stocking
- B. How to apply ice to the affected area
- C. How to do exercises to increase blood flow in the area
- D. How to dependently do activities of daily living
Correct Answer: A
Rationale: The nurse inspects the area two to three times daily and notes the client's response to antibiotic therapy. He or she gives 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. Ice does not reduce the swelling. Exercise does not reduce the swelling.
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.