A nurse is caring for a client who was admitted with bleeding esophageal varices and has an esophagogastric balloon tamponade with a Sengstaken-Blakemore tube to control the bleeding.
Which of the following actions should the nurse take?

Discharge teaching for post-radiation brain tumor patients requires understanding oncology and pharmacology. Knowledge of medication adherence, symptom monitoring for increased intracranial pressure, and integumentary protection is needed. Identifying misconceptions ensures patient safety and prevents potential neurological relapse or secondary injury.

Choice A rationale

Abrupt cessation of medications, especially anticonvulsants or steroids used in neuro-oncology, can trigger rebound edema or seizures. Maintaining therapeutic blood levels is critical for managing potential complications after radiation therapy has concluded to ensure neurological stability.

Choice B rationale

Headaches and visual disturbances are primary indicators of increased intracranial pressure or tumor recurrence. Patients must recognize these signs as urgent neurological changes that require immediate medical evaluation to prevent brain herniation or permanent functional loss.

Choice C rationale

Radiation therapy damages the DNA of skin cells, leading to thinning and increased sensitivity. Protecting the scalp from ultraviolet radiation prevents severe dermatitis and secondary burns on tissue that already has compromised healing capabilities.

Choice D rationale

Gradual reintegration into daily life is standard post-treatment advice. While energy levels dictate activity, resuming normal routines as tolerated is appropriate, provided the patient avoids hazardous activities if they have residual neurological deficits or seizure risks.

Complications of central venous access include thrombosis and malpositioning. Assessing localized edema requires objective measurement to quantify the extent of the vascular compromise. Nurses must apply the nursing process by performing a comprehensive assessment before implementing interventions or notifying the medical provider.

Choice A rationale

Measuring arm circumference provides baseline data to evaluate the severity of edema and possible deep vein thrombosis. Comparing bilateral measurements allows the nurse to quantify swelling, which is a critical assessment step before reporting findings to the physician.

Choice B rationale

Notification is necessary but should occur after the nurse has gathered objective data. Providing the clinician with specific measurements of arm circumference facilitates accurate clinical decision-making regarding potential complications like venous thrombosis or catheter-related mechanical infiltration.

Choice C rationale

Nurses generally do not remove PICC lines without a specific provider order unless there is an immediate, life-threatening emergency. Early removal without assessment might destroy vital venous access unnecessarily before the underlying cause of swelling is determined.

Choice D rationale

Cold packs cause vasoconstriction, which might be contraindicated if the swelling is due to a clot or specific medications. Interventions should only follow a complete assessment and verification of the underlying cause of the localized tissue swelling.