The partner of an older adult client who has Alzheimer's disease reports that he is not eating. The nurse observes that the client's partner refuses to assist the client with feeding. The partner insists that the client feed himself without help. Which of the following is the priority action the nurse should take?

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.

Choice A reason: Touching the hair of an African American client during an assessment does not demonstrate accurate cultural knowledge, as it may be considered disrespectful or intrusive. Hair is a sensitive and personal topic for many African Americans, who may have experienced discrimination or stigma based on their hair texture or style¹. The nurse should ask for permission before touching the client's hair and explain the purpose of the assessment.

Choice B reason: Offering to shake hands when meeting an Asian client of the opposite gender does not demonstrate accurate cultural knowledge, as it may be considered inappropriate or offensive. In some Asian cultures, physical contact between men and women who are not related or married is discouraged or prohibited². The nurse should observe the client's body language and follow the client's lead in greeting gestures.

Choice C reason: Maintaining eye contact when interviewing a Native American client does not demonstrate accurate cultural knowledge, as it may be considered rude or aggressive. In some Native American cultures, eye contact is a sign of disrespect or challenge, especially when talking to elders or authority figures³. The nurse should avoid direct eye contact and use a respectful tone of voice when interviewing the client.

Choice D reason: Including both hot and cold food items on a Hispanic client's menu demonstrates accurate cultural knowledge, as it reflects the concept of balance and harmony in Hispanic culture. Many Hispanics believe that health and illness are influenced by the balance between hot and cold forces in the body and the environment⁴. The nurse should respect the client's food preferences and beliefs and provide a variety of food options.