A female client being examined by the nurse exhibits 2+ pitting edema in the right arm, while the left arm is normal in size. Which of the following responses by the nurses is most important at this time?

Question

1. "How much salt do you have in your diet?"
2. "Does the other arm swell also?"
3. "Tell me about your past surgical procedures.".
4. "Do you ever feel self-conscious about your arm?"

Answer 1

3
Rationale 1: This client most likely has lymphedema. If salt intake was excessive, the nurse would also determine swelling in other extremities. Unilateral swelling indicates that there may be a problem with lymph drainage from the extremity.
Rationale 2: This is a good question but the nurse can see at this time that there is unilateral swelling. This is not the most important question to ask at this time.
Rationale 3: This is the most important thing for the nurse to determine. This information will help the nurse determine if the client has lymphedema due to a surgical procedure. Damage to or removal of lymph nodes can impact the ability of the lymph system to drain the arm adequately.
Rationale 4: This is important for the nurse to determine. However, this is not the most important question to ask at this time. The nurse should seek to determine how the lymphedema developed.