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 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?
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.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 of 5
A client comes to the clinic and informs the nurse of swelling in right arm. There has been no injury or precipitating occurrence that caused the swelling. The nurse observes nonpitting edema from the upper arm to the fingertips. What action should the nurse initially perform?
Correct Answer: B
Rationale: The nurse inspects and measures the affected area to assess the extent of enlargement and the condition of the skin initially. After collecting the data, the nurse may instruct the client to elevate the arm and obtain the correct size for a compression stocking. Diuretic use is not an appropriate intervention at this time and would not be administered without a physician's prescription.
Question 5 of 5
The nurse is caring for a client with lymphedema of the left arm in the clinic. The nurse measures a circumference of the affected extremity 4 cm larger in circumference than the opposite limb, and the client complains of feeling a heaviness and pain. There is limited movement of the left arm. What would the nurse grade and document this lymphedema as?
Correct Answer: C
Rationale: Grade II (Moderate), the circumference of 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. In Grade I (Mild), the circumference of the affected limb is 2 cm, but not more than 4 cm larger than the unaffected limb; the client is asymptomatic. In Grade III (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. There is no Grade IV.