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 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.
Question 2 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 3 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 4 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 5 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.