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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: You will not be taking a once weekly dose of disulfiram to help control withdrawal symptoms during treatment. Disulfiram is a medication that causes unpleasant reactions, such as nausea, vomiting, and headache, when alcohol is consumed. It is used to deter relapse, not to treat withdrawal symptoms. It is also taken daily, not weekly.
Choice B reason: Remaining physically active will not help to minimize drowsiness and chills associated with initial alcohol withdrawal. Physical activity may worsen dehydration, electrolyte imbalance, and blood pressure changes that occur during alcohol withdrawal. It may also increase the risk of seizures and delirium tremens. The nurse should monitor the client's vital signs, fluid and electrolyte status, and mental status, and administer medications as prescribed to manage withdrawal symptoms.
Choice C reason: Attending Al-Anon meetings will not help you identify a role model to assist you with making needed changes. Al-Anon is a support group for family members and friends of people with alcohol use disorder. It helps them cope with the effects of living with or caring for someone with alcohol problems. It does not provide role models or guidance for people with alcohol use disorder. The nurse should encourage the client to attend Alcoholics Anonymous (AA) meetings, which are peer support groups for people who want to stop drinking.
Choice D reason: You will begin learning functional skills to replace defense mechanisms and behaviors while in treatment. This is an appropriate statement for the nurse to include in the discussion, as it reflects one of the goals of treatment for alcohol use disorder. The nurse should help the client identify and modify the cognitive, emotional, and behavioral factors that contribute to alcohol use. The nurse should also teach the client coping skills, stress management techniques, and relapse prevention strategies.
Correct Answer is D
Explanation
Choice A reason: Encouraging the family to join a support group is not the first action that the nurse should take. This is an important intervention that can help the family cope with the challenges and stress of caring for a client who has dementia, but it should be done after the nurse has established rapport and trust with the family.
Choice B reason: Providing the family with information about respite care is not the first action that the nurse should take. This is an important intervention that can help the family access temporary relief from their caregiving responsibilities, but it should be done after the nurse has assessed the family's needs and preferences.
Choice C reason: Educating the family regarding the progression of dementia is not the first action that the nurse should take. This is an important intervention that can help the family understand the nature and course of the disease, and prepare them for the future changes and challenges, but it should be done after the nurse has evaluated the family's level of knowledge and readiness to learn.
Choice D reason: Engaging the family in informal conversation is the first action that the nurse should take. This is based on the principle of communication, which states that the nurse should initiate and maintain a therapeutic relationship with the client and the family. The nurse should use informal conversation to introduce herself, express interest and empathy, and create a comfortable and respectful atmosphere. The nurse should also use open-ended questions, active listening, and nonverbal cues to elicit the family's concerns, expectations, and goals.
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