A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis.
The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements.
Which factor is the most likely cause for this problem?
Nausea.
Fatigue.
Pain when eating.
Altered taste sensation.
The Correct Answer is C
Choice A rationale:
Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.
Choice B rationale:
Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.
Choice C rationale:
Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.
Choice D rationale:
Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
The correct answers are Choices B, C, D, and E.
Choice A rationale: Dentures should remain in place to preserve facial structure and dignity. Removing them may cause facial collapse, distressing the family during viewing and violating postmortem presentation standards.
Choice B rationale: Gently closing the eyes prevents ocular drying and maintains a peaceful appearance. If eyelids resist closure, moistened cotton balls may be used temporarily to assist with natural positioning.
Choice C rationale: Placing a small pillow under the head elevates it, preventing blood pooling and facial discoloration due to livor mortis. It supports a natural, respectful presentation for family viewing.
Choice D rationale: Applying a body shroud ensures hygienic containment and visual dignity. It’s standard practice before transport and aligns with institutional protocols for respectful postmortem care.
Choice E rationale: Removing resuscitation equipment reduces trauma triggers for the family, restores environmental calm, and supports emotional closure. It also complies with facility standards for postmortem room preparation.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I should avoid foods that are high in vitamin K," indicates an understanding of the medication. Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Consistent intake of vitamin K-containing foods helps maintain a stable INR (International Normalized Ratio) and warfarin's effectiveness. Clients on warfarin should be educated about avoiding drastic changes in their vitamin K intake.
Choice B rationale:
Taking warfarin with food or on an empty stomach doesn't significantly impact its efficacy. Therefore, this statement is not indicative of the client's understanding of the medication.
Choice C rationale:
The statement "I should report any unusual bleeding or bruising to my provider" is important but doesn't specifically reflect an understanding of warfarin. It's a general caution for anyone taking anticoagulants.
Choice D rationale:
While it's important to avoid excessive use of medications like aspirin that can increase the risk of bleeding, this statement doesn't directly demonstrate an understanding of warfarin itself.
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