The nurse is teaching a client with cancer about skin care for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?

Choice A reason: Presenting a calm, supportive demeanor is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should use a soothing tone of voice, maintain eye contact, and avoid arguing or challenging the client's perceptions. This can help reduce the client's agitation and promote trust.

Choice B reason: Reorienting to day and time frequently is an appropriate intervention for a client who is experiencing anxiety and hallucinations. The nurse should provide reality-based information and reminders about the client's situation, such as the reason for hospitalization, the name of the nurse, and the expected plan of care. This can help the client regain a sense of orientation and control.

Choice C reason: Administering an as needed (PRN) dose of lorazepam is an appropriate intervention for a client who is experiencing anxiety and hallucinations. Lorazepam is a benzodiazepine that can reduce anxiety, agitation, and psychotic symptoms by enhancing the effects of gamma-aminobutyric acid (GABA), an inhibitory neurotransmitter in the brain. The nurse should monitor the client's vital signs, level of sedation, and risk of falls after giving the medication.

Choice D reason: Turning the television on for distraction is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. The television can increase the sensory stimulation and confusion for the client, and may worsen the hallucinations or delusions. The nurse should provide a quiet and safe environment for the client.

Choice E reason: Applying soft wrist restraints bilaterally is not an appropriate intervention for a client who is experiencing anxiety and hallucinations. Restraints can increase the anxiety and agitation for the client, and may cause physical or psychological harm. The nurse should use restraints only as a last resort when other less restrictive measures have failed to protect the client or others from harm.

Choice A reason: Redness and edema noted at the incision site are signs of inflammation, which are normal in the early stages of wound healing. The nurse should monitor the site for signs of infection, such as purulent drainage, increased pain, or fever.

Choice B reason: Apical heart rate of 100 to 110 beats/minute is a sign of tachycardia, which may be caused by pain, anxiety, dehydration, or blood loss. The nurse should assess the client's vital signs, fluid status, and hemoglobin level, and administer pain medication as prescribed.

Choice C reason: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.

Choice D reason: Pain rating of 8 on a scale of 0 to 10 is a sign of severe pain, which may impair the client's recovery and increase the risk of complications. The nurse should administer pain medication as prescribed and use non-pharmacological methods to relieve pain, such as positioning, distraction, or relaxation techniques.