A home health nurse is caring for a client who has chemotherapy-induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply)
Use seasonings to enhance the flavor of foods.
Provide sips of room temperature ginger ale between meals.
Maintain the head of the client's bed in an elevated position after eating.
Offer 120 ml (4 oz.) of cold 2% milk as a meal replacement.
Assist the client in using guided imagery.
Correct Answer : B,C,E
Choice A reason: Using seasonings to enhance the flavor of foods is not an intervention that the nurse should initiate. This may worsen the nausea and vomiting, as some seasonings may be too spicy, salty, or acidic for the client. The nurse should advise the client to avoid foods that are greasy, fried, or have strong odors, and to choose bland, soft, or liquid foods that are easy to digest.
Choice B reason: Providing sips of room temperature ginger ale between meals is an intervention that the nurse should initiate. This can help to settle the stomach and reduce the nausea and vomiting. Ginger has antiemetic properties that can inhibit the serotonin receptors in the gastrointestinal tract. The nurse should also encourage the client to drink plenty of fluids to prevent dehydration.
Choice C reason: Maintaining the head of the client's bed in an elevated position after eating is an intervention that the nurse should initiate. This can help to prevent the reflux of gastric contents and reduce the nausea and vomiting. The nurse should also instruct the client to eat small, frequent meals, and to avoid lying down for at least an hour after eating.
Choice D reason: Offering 120 ml (4 oz.) of cold 2% milk as a meal replacement is not an intervention that the nurse should initiate. This may worsen the nausea and vomiting, as milk and dairy products may be difficult to digest and may increase the production of mucus. The nurse should suggest other sources of protein and calcium, such as soy milk, yogurt, or cheese.
Choice E reason: Assisting the client in using guided imagery is an intervention that the nurse should initiate. This can help to reduce the nausea and vomiting, as well as the anxiety and stress associated with chemotherapy. Guided imagery is a relaxation technique that involves creating positive mental images that can distract the client from the unpleasant sensations and feelings. The nurse should help the client to choose an image that is soothing and comforting, and to focus on the sensory details of the image.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Giving positive feedback to students who make appropriate choices is a good strategy to reinforce healthy eating, but it is not the first action that the nurse should take. The nurse should first assess the students' readiness to learn and their motivation to change their behavior.
Choice B reason: Helping students recognize the value of making healthy food choices is an important goal of the program, but it is not the first action that the nurse should take. The nurse should first determine the students' current knowledge, attitudes, and beliefs about healthy eating and tailor the program accordingly.
Choice C reason: Providing students with resources about making wise choices independently is a useful way to support their learning, but it is not the first action that the nurse should take. The nurse should first identify the barriers and facilitators that influence the students' food choices and address them in the program.
Choice D reason: Determining students' motivation to learn about healthy food choices is the first action that the nurse should take. This is based on the principle of learner-centered education, which states that the nurse should assess the learners' needs, interests, and readiness to learn before planning and implementing the program.
Correct Answer is C
Explanation
Choice A reason: Alerting the family members of coworkers about possible exposure to anthrax is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The family members of coworkers are not at risk of infection, and alerting them may cause unnecessary panic and stigma.
Choice B reason: Placing the employee under quarantine for 14 days is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to be isolated from others, and quarantine may interfere with their access to medical care and social support.
Choice C reason: Referring coworkers who might have been exposed to a provider for prophylactic antibiotics is an action that the nurse should take. Anthrax is a serious bacterial infection that can be fatal if left untreated. The coworkers who might have been exposed to the same source of anthrax as the employee should receive prophylactic antibiotics as soon as possible to prevent the infection from developing.
Choice D reason: Instructing the employee to wear a mask at work is not an action that the nurse should take. Anthrax is not contagious, and it cannot be spread from person to person. The employee does not need to wear a mask at work, and doing so may cause unnecessary discomfort and discrimination.
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