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 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.
Question 2 of 5
An adolescent client diagnosed with infectious mononucleosis asks the nurse if it is possible to keep getting the disease in the future. What is the best response by the nurse?
Correct Answer: C
Rationale: One episode of infectious mononucleosis produces subsequent immunity; however, the virus remains in the body for the person's lifetime. The virus does not dissipate and go away. If a client has an incidence of infection, the client is immune from further infections of Epstein-Barr virus. The symptoms do not generally go away for 2 to 6 weeks.
Question 3 of 5
The nurse is caring for a group of clients. Which client does the nurse suspect is most likely to have mononucleosis?
Correct Answer: B
Rationale: The virus most commonly affects young adults, especially those in close living quarters, such as armed services housing and college dormitories. Fatigue, fever, sore throat, headache, and cervical lymph node enlargement typically occur. The tonsils ooze white or greenish-gray exudates. Pharyngeal swelling can compromise swallowing and breathing. Some clients develop a faint red rash on their hands or abdomen. The liver and spleen become enlarged. The other clients with presenting symptoms do not correlate with the symptoms of mononucleosis.
Question 4 of 5
A teenaged client arrives at the clinic and reports having attended 2 weeks of summer camp last month and now is not feeling well with complaints of sore throat, fever, and feeling very tired. The nurse observes white exudate on the tonsils. What test does the nurse anticipate the physician will order for this client?
Correct Answer: A
Rationale: A positive slide agglutination test (Monospot, Monotest, Monosticon) is presumptive evidence that the Epstein-Barr virus is causing the symptoms. A rise in the Epstein-Barr virus antibody titer and a heterophil agglutination test result of 1:224 or greater is conclusive for infectious mononucleosis. The AST and ALT would indicate possible liver disorders. A glucose level would not be indicative of Epstein-Barr virus. T3, T4, and TSH would be indicative of thyroid dysfunction, which the client's age and symptoms do not correlate with.
Question 5 of 5
A client with Hodgkin's disease has a weight loss of 10% of body weight 6 months prior to the diagnosis, fever of 101?°F, and drenching night sweats. What sub classification of Hodgkin's disease does this client fit into?
Correct Answer: B
Rationale: Stages I, II, III, and IV of adult Hodgkin's disease are subclassified into A and B categories: B for those with defined general symptoms and A for those without B symptoms. The B designation is given to client with any of the following symptoms: unexplained loss of more than 10% of body weight in 6 months before diagnosis, unexplained fever with temperatures over 100.4?°F, and drenching night sweats. There is no sub classification of C or D.