A nurse is creating a plan of care for a client who has cancer and is experiencing Immunosuppression. Which of the following Interventions should the nurse include in the plan of care?
Monitor the client's vital signs every 12 hr.
Inspect the client's mouth every 8 hr.
Provide fresh fruit with the client's meals.
Rotate health care staff caring for the client.
The Correct Answer is B
A. Monitoring vital signs every 12 hours is a standard nursing intervention but may not specifically address the needs of a client with immunosuppression.
B. Inspecting the client's mouth every 8 hours can help in early detection of mouth sores or infections, which are common in immunosuppressed individuals.
C. Providing fresh fruit with meals may not be appropriate for a client with immunosuppression, as fresh fruits can harbor pathogens that pose a risk of infection.
D. Rotating healthcare staff caring for the client helps increases the risk of introducing pathogens to the client. This increases the risk of infection in the immunosuppressed client.
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Related Questions
Correct Answer is B
Explanation
A. Informing the client that their name cannot be removed once listed may deter individuals from considering organ donation. In reality, individuals can update or revoke their consent at any time.
B. Organ donation requires documented consent, either through advance directives or donor registry enrollment. Verbal consent alone is not sufficient. The nurse should educate the client about the importance of documenting their wishes regarding organ donation.
C. Declaring that the nurse cannot be a witness for consent is inaccurate. Witnesses may be required depending on local regulations, but healthcare professionals can serve as witnesses.
D. Specifying a minimum age requirement for organ donation is incorrect. Organ donation eligibility depends on various factors beyond age, such as overall health and the condition of organs at the time of death.
Correct Answer is C
Explanation
A. While rest and a quiet environment can be beneficial, encouraging the client to address the hallucinations directly is more appropriate.
B. Avoiding eye contact may be perceived as dismissive or unhelpful.
C. Engaging the client in open communication about their hallucinations can help build trust and rapport, as well as provide valuable information for treatment planning.
D. Validating hallucinations as real can reinforce delusional thinking and may not be therapeutically beneficial.
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