The nurse is caring for a client, who returned from the tropics a few weeks ago and who sought care with signs and symptoms of lymphedema. The nurse's plan of care should prioritize what nursing diagnosis?
Risk for deficient fluid volume related to lymphedema
Ineffective health maintenance related to lymphedema
Risk for infection related to lymphedema
Disturbed body image related to lymphedema
The Correct Answer is C
A. Lymphedema involves fluid accumulation in tissues, not fluid loss, so the client is not at risk for deficient fluid volume.
B. While health maintenance may be affected, it is not the immediate priority.
C. Lymphedema causes stagnant lymph fluid, which creates a fertile environment for bacterial growth, making infection a primary concern.
D. Body image may be affected long-term, but preventing infection takes precedence in acute care planning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Offering a snack is not necessary before digoxin administration.
B. While monitoring blood pressure is important overall, it is not the priority before giving digoxin.
C. Measuring the apical pulse for 1 full minute is essential before administering digoxin because the medication can cause bradycardia. If the pulse is less than 60 beats per minute, the nurse should withhold the medication and notify the provider.
D. Weighing the client helps monitor fluid status but is not required immediately before digoxin administration.
Correct Answer is A
Explanation
A. Placing the tablet under the tongue allows for rapid absorption through the mucous membranes, providing quick relief of anginal pain—typically within 1 to 3 minutes.
B. Nitroglycerin acts quickly; waiting up to 15 minutes is not accurate. Clients should seek emergency care if pain persists after 3 doses taken 5 minutes apart.
C. Headache is a common side effect due to vasodilation and is not a reason to discontinue the medication; clients can manage it with mild analgesics.
D. Clients may take nitroglycerin prophylactically before activities (e.g., exercise, sexual activity) that may trigger angina. Avoiding use prior to exertion is not recommended.
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