1.The family nurse practitioner is performing a physical assessment on a client with a
suspected lymphatic disorder. What would be the nurse practitioner's primary assessment
for all clients with lymphatic disorders?
A) Fever and sore throat
B) Painful joints
C) Signs of leukopenia and thrombo...
1.The family nurse practitioner is performing a physical assessment on a client with a
suspected lymphatic disorder. What would be the nurse practitioner's primary assessment
for all clients with lymphatic disorders?
A) Fever and sore throat
B) Painful joints
C) Signs of leukopenia and thrombocytopenia
D) Enlargement of the lymph glands
Ans: D
Feedback:
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.
2.A client has just been admitted to your 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?
A) Are you experiencing fever, chills, or night sweats?
B) Do you use artificial respirators?
C) Have you ever had a blood transfusion?
D) Have you ever experienced fractures?
Ans: A
Feedback:
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.
3.Your client is receiving chemotherapy for a diagnosis of lymphosarcoma. The client
experiences nausea. What measures should the nurse suggest to help the client reduce the
feeling of nausea?
A) Administer immunosuppressive drugs.
B) Apply ice to the skin for brief periods.
C) Offer clear liquids such as carbonated beverages, water, and ice pops.
D) Advise bed rest as much as possible.
Ans: C
Feedback:
To help reduce the feeling of nausea in a client who underwent chemotherapy, the nurse
should offer clear liquids such as carbonated beverages, water, ice pops, and gelatin until
the nausea subsides. Immunosuppressive drugs are known to cause non-Hodgkin's
lymphoma when administered to prevent a transplant rejection. These drugs do not help
in reducing the feeling of nausea. The nurse may need to apply ice to the skin to prevent
Page 1
, it from itching and thereby promote the skin integrity. Bed rest, analgesic and antipyretic
therapy, and increased fluid intake are recommended to clients with infectious
mononucleosis.
4.A 55-year-old female client has developed lymphedema postmastectomy. What is the
common method used to promote lymphatic drainage and prevent edema in all clients
with lymphedema?
A) Reduce the intake of fluids.
B) Avoid exercising the affected part.
C) Decrease the intake of sodium and calcium.
D) Elevate the affected part of the body.
Ans: D
Feedback:
Treatment usually is symptomatic. In the early stages, the client elevates the affected part
to promote lymphatic drainage. Exercising the affected part in the client helps in
promoting the lymphatic circulation and maintaining the functional use of the limb.
Reducing the sodium and calcium intake or fluids does not promote lymphatic drainage
or prevent edema.
5.A client with lymphadenitis has developed persistent swelling of the affected area. What
would be important information for you to teach this client?
A) How to apply an elastic sleeve or stocking
B) How to apply ice to the affected area
C) How to do exercises to increase blood flow in the area
D) How to dependently do activities of daily living
Ans: A
Feedback:
The nurse inspects the area two to three times daily and notes the client's response to
antibiotic therapy. He or she gives 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. Ice does not reduce the swelling. Exercise does not reduce the
swelling.
6.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?
A) Eat warm food and drink warm liquids.
B) Eat soft, bland foods and drink cool liquids.
C) Avoid spicy foods and drink warm liquids.
D) Eat soft, bland foods and drink warm liquids.
Ans: B
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