A home health nurse is caring for a client who has chemotherapy-induced nausea that has been resistant to relief from pharmacological measures. Which of the following interventions should the nurse initiate? (Select all that apply.)
Maintain the head of the client's bed in an elevated position after eating.
Provide sips of room-temperature ginger ale between meals.
Offer 120 mL (4 oz) of cold milk as a meal replacement.
Use seasonings to enhance the flavor of foods.
Assist the client in using guided imagery.
Correct Answer : B,E
Interventions for Chemotherapy-Induced Nausea: Analyzing the Choices
The prompt describes a home health nurse caring for a client experiencing chemotherapy-induced nausea resistant to pharmacological interventions. We need to analyze the effectiveness of each offered intervention based on evidence and rationale:
a. Maintain the head of the client's bed in an elevated position after eating.
Rationale:
- Supportive: Some studies suggest elevating the head of the bed by 30-45 degrees might reduce gastroesophageal reflux and nausea after meals. However, the effectiveness remains inconclusive, and further research is needed.
- Potential drawbacks: This position may be uncomfortable for some clients, especially those with respiratory difficulties.
b. Provide sips of room-temperature ginger ale between meals.
Rationale:
- Supportive: Ginger has demonstrated antiemetic properties in several studies, potentially reducing nausea and vomiting. Room-temperature liquids are generally better tolerated than cold or hot ones for nausea.
- Considerations: The effectiveness of ginger may vary between individuals, and potential interactions with other medications should be checked.
c. Offer 120 mL (4 oz) of cold milk as a meal replacement.
Rationale:
- Unsupportive: Replacing meals with small volumes of milk is inadequate for nutritional needs and can worsen nausea due to an empty stomach. Chemotherapy can already impact appetite and nutrient intake, and offering small, frequent meals is generally recommended.
- Potential harm: Skipping meals can lead to electrolyte imbalances, dehydration, and further weaken the client.
d. Use seasonings to enhance the flavor of foods.
Rationale:
- Mixed evidence: While strong odors or unfamiliar flavors can trigger nausea in some clients, using bland or mild seasonings might not be universally effective. Some studies suggest offering preferred or familiar flavors based on individual preferences could improve appetite and tolerance.
- Individualization: Experimenting with different spices and flavors based on the client's preferences and observing their response is crucial.
e. Assist the client in using guided imagery.
Rationale:
- Supportive: Guided imagery is a relaxation technique that can help manage nausea by distracting the client from the unpleasant sensation and promoting feelings of calmness. Studies have shown its effectiveness in reducing nausea and vomiting in various contexts, including chemotherapy.
- Considerations: Not all clients may be receptive to guided imagery, and its success depends on individual preferences and practice.
In conclusion, the most appropriate interventions for the client include:
- Providing sips of room-temperature ginger ale between meals (choice b).
- Assisting the client in using guided imagery (choice e).
Choices a, c, and d require further evaluation or are not generally recommended based on current evidence.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is Choice D because "Explore possible solutions with the partner." When a hospice nurse is concerned that the partner of a client is experiencing caregiver burden, the first step is to explore possible solutions with the partner. This involves assessing the partner's needs, concerns, and limitations, and working collaboratively to develop a plan of care that meets the needs of both the client and the partner. This may involve arranging for additional support, such as respite care or home health services, or modifying the care plan to make it more manageable for the partner.
Choice A is wrong because Suggesting assistive personnel visits daily to provide client care (Choice A is wrong because) may provide additional support, but it does not address the partner's caregiver burden.
Choice B is wrong because Teaching the partner about getting enough rest (Choice B is wrong because) may be helpful, but it does not address the underlying caregiver burden and may be perceived as dismissive of the partner's concerns.
Choice C is wrong because Encouraging the partner to invite family members to assist with client care (Choice C is wrong because) may provide additional support, but it assumes that the partner has family members who are available and willing to assist and does not address the underlying caregiver burden.
Correct Answer is B
Explanation
The correct answer is Choice B because, don personal protective equipment. The nurse should protect herself first by putting on personal protective equipment to prevent contamination and further spread of the suspected bioterrorism agent.
Choice A is wrong because, report the client's condition to the Federal Bureau of Investigation, is incorrect as this is not the primary role of the nurse, and the client's condition should be reported to the local public health department. Choice C is wrong because, disinfect contaminated areas of skin with isopropyl alcohol, is incorrect as this is not a recommended treatment for bioterrorism-related illnesses, and the nurse should avoid touching the client or any contaminated items. Choice D is wrong because, move the client to a quarantine area, is incorrect as the nurse should not move the client, but instead limit contact with the client and follow established infection control protocols.
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