Which nursing intervention is the most appropriate to implement for a client who experiencing weight loss due to nausea caused by chemotherapy?
Withhold solid foods and switch the client to liquid nutrition
Encourage the client to consume small, frequent meals throughout the day
Teach the client to eat one large meal per day to increase calorie intake
Insert a nasogastric tube and administer tube feedings
The Correct Answer is B
A. Automatically switching to liquid nutrition without assessing the client’s tolerance and needs may not be the most appropriate first step. It’s important to consider the client’s preferences, nutritional requirements, and overall ability to tolerate different types of food.
B. This is a highly appropriate and commonly recommended intervention for clients experiencing nausea and weight loss due to chemotherapy. Small, frequent meals can help manage nausea better than large meals and ensure a more consistent intake of calories and nutrients.
C. Eating one large meal per day is generally not advisable for clients with nausea, as it can exacerbate feelings of fullness and discomfort. Large meals may increase nausea and make it more difficult for the client to consume adequate nutrients. Small, frequent meals are generally better tolerated and more effective for managing nausea and ensuring consistent nutrient intake.
D. Inserting a nasogastric (NG) tube and administering tube feedings is a more invasive measure and is usually considered only if oral intake is severely compromised and other interventions have been ineffective. Tube feedings are appropriate for clients who cannot meet their nutritional needs through oral intake due to severe nausea, vomiting, or other conditions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cool, clammy skin can be a sign of a myocardial infarction. It occurs due to the body's stress response during an MI, leading to decreased perfusion and sweating. This symptom is consistent with the autonomic response to a heart attack.
B. Chest pain radiating into the back, jaw, or arms is a classic symptom of myocardial infarction. This radiation of pain is due to the way pain signals are transmitted and referred from the heart to other parts of the body. It is a common and significant symptom of MI.
C. Nausea and vomiting can occur during a myocardial infarction, particularly in older adults. These symptoms are related to the autonomic nervous system's response to the stress of an MI and can sometimes be the presenting symptoms, especially in women and older adults.
D. Peripheral edema is generally not a direct symptom of myocardial infarction. It is more commonly associated with chronic heart failure or other conditions leading to fluid overload. While MI can lead to heart failure over time, peripheral edema itself is not a typical acute symptom of an MI.
Correct Answer is D
Explanation
A. The ACTH stimulation test measures the adrenal glands' response to ACTH, not the kidneys.
B. In Addison’s disease, the adrenal glands are damaged and unable to produce sufficient cortisol even when stimulated by ACTH. Therefore, plasma cortisol levels will not rise significantly in response to
ACTH administration in individuals with Addison’s disease.
C. The ACTH stimulation test involves administering ACTH via injection, not orally.
D. ACTH (adrenocorticotropic hormone) is produced by the pituitary gland and stimulates the adrenal glands to produce cortisol. The ACTH stimulation test assesses how well the adrenal glands respond to ACTH, which is crucial for diagnosing conditions like Addison’s disease, where the adrenal glands do not respond appropriately.
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