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
The nurse is caring for a client newly admitted to the unit with a diagnosis of lymphangitis. What intervention(s) would the nurse institute to help promote the resolution of the lymphangitis? Select all that apply.
Correct Answer: B,C,D,E
Rationale: The nurse inspects the area two to three times daily and notes the client's response to antibiotic therapy, giving 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.
Question 2 of 5
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.
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.
Question 3 of 5
The nurse is providing instruction on the use of compression garments for the client with lymphedema. What should be included in the instructions? Select all that apply.
Correct Answer: A,B,C
Rationale: When instructing the client on use of the compression garment, purchase two compression garments so that one can be worn while the other is washed and dried. Change the garment in the morning and again in the evening because the garment becomes stretched after 12 hours of being worn. Limit the time that the garment is not worn to no more than 30 to 60 minutes to prevent re accumulation of tissue fluid and stretched skin. The garment should be replaced every 4 to 6 months, not every month. The garment should be air dried, not placed in the dryer.
Question 4 of 5
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?
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.
Question 5 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.