The nurse is assessing a client admitted to the hospital for congestive heart failure and notes 1+ pitting edema of the left arm, as well as bilateral 1+ pitting edema in the client's ankles
The client's history indicates that the client has had a myocardial infarction and a left mastectomy. The nurse would suspect which of the following causes for the edema in the left arm? 1. Impaired lymphatic drainage
2. Noncompliance with medication regimen
3. Right-sided heart failure
4. Excessive intake of sodium
1
Rationale 1: This client most likely has developed lymphedema due to the removal of lymph nodes during the client's mastectomy. This type of surgery can inhibit the body's ability to drain lymph from the client's affected arm.
Rationale 2: Noncompliance with medication may result in edema that affects the client's bilateral peripheral extremities. Unilateral edema indicates that there is a problem with the way the lymph is able to drain from the client's extremity.
Rationale 3: Right-sided heart failure often results in bilateral pitting edema. Unilateral pitting edema indicates that the lymph is not draining well from the client's arm.
Rationale 4: Increased sodium intake can result in edema. However, this would most likely result in bilateral peripheral edema.
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