ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 32 : Caring for Clients With Disorders of the Lymphatic System Questions
Question 1 of 5
A client has just been admitted to the unit with a diagnosis of Hodgkin's disease. When doing the initial assessment, what pertinent questions should the nurse ask the client to help determine the correct nursing diagnosis?
Correct Answer: A
Rationale: In a client with Hodgkin's disease, the nurse should ask how long the client has noticed the enlarged lymph nodes. The nurse checks for the presence and the extent of tenderness in the area of the lymph node enlargement. The nurse should also ask the client about fever, chills, or night sweats. It is not pertinent to ask the client about any previous history of fractures, the use of artificial respirators, or any blood transfusions.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 of 5
A client with lymphadenitis has developed persistent swelling of the affected area. What would be important information for the nurse to teach this client?
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.
Question 5 of 5
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?
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.