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 with lymphedema in the left arm has weeping from the skin and has a small 2-cm ulcer on the upper arm. What test does the nurse anticipate the client will be prepared for?
Correct Answer: D
Rationale: Lymphangiography is a special examination in which an intravenous dye and radiography are used to detect lymph node involvement that reveals the degree and extent of blockage in the lymph system. An x-ray of the arm, ultrasound, or CT scan will not reveal the extent of blockage.
Question 2 of 5
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?
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.
Question 3 of 5
A client has developed an infection that resulted in lymphangitis. What does the nurse suspect the causative organism is that caused the infection?
Correct Answer: A
Rationale: An infectious agent, commonly a streptococcal microorganism, usually causes both lymphangitis and lymphadenitis. It is not commonly caused by staph, E. coli, or C. albicans (a fungal infection).
Question 4 of 5
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?
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.
Question 5 of 5
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?
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.