The nurse is assessing a client admitted to the hospital for ...

[nenivikky]

The nurse is assessing a client admitted to the hospital for congestive heart failure (CHF) 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. Which is the most probable cause of the edema in the client's left arm?
  1. Impaired lymphatic drainage.
  2. Noncompliance with medication regimen.
  3. Right-sided heart failure.
  4. Excessive intake of sodium.

Question 2

The nurse is documenting an ulcer on the lateral aspect of the client's right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding.
 
  Which other assessment data would be useful to determine the origin of this client's ulcer?
  1. Skin turgor.
  2. Calf measurements.
  3. Homan's sign.
  4. Peripheral pulses.

[Andromeda18]

Answer to Question 1

Correct Answer: 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. 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. 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. Increased sodium intake can result in edema; however, this would most likely result in bilateral peripheral edema.

Answer to Question 2

Correct Answer: 4
Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time. The nurse can use information about the client's skin turgor to help assess the client's fluid balance. Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency. Homan's sign can be used to help determine if the client has developed a deep vein thrombosis.