A nurse is planning care for a client who is receiving radiation therapy to treat throat cancer and reports a change in the taste of food. Which of the following interventions should the nurse include in the plan of care?
Offer artificial saliva frequently.
Provide three large meals daily.
Add honey to sweeten fruit smoothies.
Heat food before serving.
The Correct Answer is A
Choice A: This is correct because offering artificial saliva frequently can help moisten the mouth and improve the taste of food. Radiation therapy can cause dry mouth and altered taste sensation.
Choice B: This is incorrect because providing three large meals daily can be overwhelming and unappetizing for the client. The nurse should provide small, frequent meals that are high in protein and calories.
Choice C: This is incorrect because adding honey to sweeten fruit smoothies can irritate the throat and increase the risk of infection. The nurse should avoid foods that are acidic, spicy, or sticky.
Choice D: This is incorrect because heating food before serving can enhance the unpleasant taste and smell of food. The nurse should serve food cold or at room temperature.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: The nurse should contact the provider to clarify the prescription because applying heat to an area with impaired sensation can cause burns or tissue damage. The nurse should also educate the client about the risks of using heat therapy and alternative methods to relieve pain.
Choice B reason: The Semmes Weinstein monofilament test is used to assess the sensation of light touch in clients with peripheral neuropathy. The nurse should perform this test before applying any intervention that could affect the skin integrity, such as heat, cold, or compression.
Choice C reason: Observing the skin 10 min after the start of treatment is not sufficient to prevent complications from heat therapy. The nurse should monitor the skin continuously and check for signs of redness, blisters, or burns.
Choice D reason: Applying the heating pad as prescribed by the provider is not appropriate for a client with diabetic neuropathy of the lower extremities. Heat can increase blood flow and inflammation in the affected area, which can worsen the condition and increase the risk of infection.
Correct Answer is B
Explanation
Choice A reason: Keeping both arms below the level of the client's heart can increase venous pressure and fluid accumulation in the affected arm, which can lead to lymphedema.
Choice B reason: After a mastectomy, it’s important to avoid procedures like blood draws, injections, or blood pressure measurements on the side where the surgery was performed to prevent lymphedema. Therefore, using the client’s left arm for blood samples is a preventive measure.
Choice C reason: Obtaining blood pressure readings using the client's right arm is an incorrect action that can increase lymphatic fluid accumulation and impair circulation in the affected arm.
Choice D reason: Limiting range-of-motion exercises with the affected arm is an incorrect action that can decrease lymphatic drainage and increase swelling in the affected arm. The nurse should encourage the client to perform gentle exercises, such as squeezing a soft ball or raising and lowering the arm, to promote lymphatic flow and prevent stiffness.
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