Nokea
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.
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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 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.
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.
The client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client experiences nausea. What measures should the nurse suggest to help the client reduce the feeling of nausea?
- A. Administer immunosuppressive drugs.
- B. Apply ice to the skin for brief periods.
- C. Offer clear liquids such as carbonated beverages, water, and ice pops.
- D. Advise bed rest as much as possible.
Correct Answer: C
Rationale: To help reduce the feeling of nausea in a client who underwent chemotherapy, the nurse should offer clear liquids such as carbonated beverages, water, ice pops, and gelatin until the nausea subsides. Immunosuppressive drugs are known to cause non-Hodgkin's lymphoma when administered to prevent a transplant rejection. These drugs do not help in reducing the feeling of nausea. The nurse may need to apply ice to the skin to prevent it from itching and thereby promote the skin integrity. Bed rest, analgesic and antipyretic therapy, and increased fluid intake are recommended to clients with infectious mononucleosis.
The nurse is caring for a client with lymphangitis of the right leg who is receiving treatment with a broad-spectrum antibiotic. The nurse is giving a bath and observes the right leg is larger than it was 2 hours ago, and the client feels hot. What is the first action by the nurse?
- A. Place the leg below the level of the heart.
- B. Notify the physician.
- C. Place cool compresses on the extremity.
- D. Begin performing passive range of motion exercises.
Correct Answer: B
Rationale: 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 leg should be elevated to reduce the edema. A warm compress may be applied to promote comfort and enhance circulation. Passive range of motion would be contraindicated at this time.