ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 32 Questions
Question 1 of 5
The nurse is caring for a client diagnosed with infectious mononucleosis who is having trouble eating. What would the nurse advise this client to improve his oral intake?
Correct Answer: B
Rationale: The nurse inspects the client's throat for the extent of inflammation or edema. He or she gently palpates the lymph nodes to detect swelling and encourages fluids. Soft, bland foods and cool liquids are best for clients with ulcerations of the oral mucosa. Warm food and liquids and spicy food are not recommended.
Question 2 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 3 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 4 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 5 of 5
The nurse is caring for a client with Hodgkin's disease who has developed anemia. What would the nurse expect to be prescribed for this client?
Correct Answer: B
Rationale: Transfusions are prescribed to control anemia. If resistance to treatment develops, autologous bone marrow or peripheral stem cells are harvested, followed by high doses of chemotherapy that destroy the bone marrow. A transplant is performed after separating the normal stem cells from the malignant cells in the harvested specimen. Lower doses of radiation, breaks in chemotherapy, and increased rest and fluid are not considered part of the treatment regimen for anemia.