The nurse is collecting objective data from the client with lymphedema of the left leg. The nurse observes that the affected leg is 10 cm greater in measurement than the unaffected leg. The affected leg is hot to the touch and red
What classification of lymphedema does the nurse recognize this client has? A) Grade I (Mild)
B) Grade II (Moderate)
C) Grade III (Severe)
D) Grade IV (Extreme)
C
Feedback:
In severe, the circumference of the affected limb is 8 cm greater than the unaffected limb, involves the entire limb, or is accompanied by infection or cellulitis (inflammation of connective tissue in or close to the skin). Mild is the circumference of the limb is 2 cm, but not more than 4 cm larger than the unaffected limb; client is asymptomatic. Moderate lymphedema is the circumference of the affected limb is 4 cm, but not more than 8 cm larger than the unaffected limb; client experiences symptoms such as heaviness in the limb, pain, and limited movement. There is no classification considered extreme.
You might also like to view...
A patient's intravenous (IV) injection has been infusing at a very high rate. What assessment indicates fluid volume overload in this patient?
a. Hypotension b. Tachycardia c. Pulmonary edema d. Kidney failure
A client is brought to the emergency department in a confused state, with slurred speech, characteristics of a headache, and right facial droop
The vital signs reveal a blood pressure of 170/88 mm Hg, pulse of 92 beats/minute, and respirations at 24 breaths/minute. On which bodily system does the nurse focus the nursing assessment? A) Cardiovascular system B) Respiratory system C) Endocrine system D) Neurovascular system
A group of nursing students is reviewing the various agents used to treat insomnia. The students demonstrate an understanding of the information when they identify which agent as a melatonin receptor agonist?
A) Trazodone B) Estazolam C) Mirtazapine D) Ramelteon
It is most appropriate to take medications to reduce serum phosphorus levels
a. with fluids. b. with meals. c. between meals. d. one hour after meals.