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)

Use seasonings to enhance the flavor of foods.

Provide sips of room temperature ginger ale between meals.

Maintain the head of the client's bed in an elevated position after eating.

Offer 120 ml (4 oz.) of cold 2% milk as a meal replacement.

Assist the client in using guided imagery.

Answer and Explanation

Correct Answer : B,C,E

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.

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Correct Answer is C

Explanation

Choice A reason: Blood pressure screening is not the first thing that the nurse should perform, as it is a physical assessment that can be done later in the visit. Blood pressure screening is important to monitor the client's cardiovascular health and risk of hypertension, but it is not a priority for the initial visit.

Choice B reason: Mental status examination is not the first thing that the nurse should perform, as it is a psychological assessment that can be done later in the visit. Mental status examination is important to evaluate the client's cognitive, emotional, and behavioral functioning and identify any mental health issues, but it is not a priority for the initial visit.

Choice C reason: Review of the neighborhood is the first thing that the nurse should perform, as it is an environmental assessment that can provide valuable information about the client's living conditions, safety, and resources. Review of the neighborhood is important to identify any potential hazards, barriers, or needs that may affect the client's health and well-being, and to plan appropriate interventions and referrals.

Choice D reason: Family history is not the first thing that the nurse should perform, as it is a genetic and social assessment that can be done later in the visit. Family history is important to determine the client's risk of inheriting or developing certain diseases, and to understand the client's family dynamics and support system, but it is not a priority for the initial visit.

A. Have the client's daughter communicate information about the procedure. B. Arrange for a member of the client's community to interpret the teaching. C. Identify the client's spoken dialect prior to contacting an interpreter. D. Use professional terminology when providing education prior to the procedure.

Correct Answer is C

Explanation

Choice A reason: Having the client's daughter communicate information about the procedure is not an action that the nurse should take. The daughter may not be a reliable or accurate interpreter, as she may have limited language skills, lack medical knowledge, or be influenced by her emotions or biases. The nurse should use a qualified interpreter who can ensure the confidentiality, accuracy, and completeness of the communication.

Choice B reason: Arranging for a member of the client's community to interpret the teaching is not an action that the nurse should take. The member of the client's community may not be a qualified or impartial interpreter, as he or she may have a personal or professional relationship with the client, or may have a conflict of interest or a hidden agenda. The nurse should use a professional interpreter who can maintain the boundaries, objectivity, and neutrality of the communication.

Choice C reason: Identifying the client's spoken dialect prior to contacting an interpreter is an action that the nurse should take. This will help the nurse to find an appropriate interpreter who can communicate effectively and respectfully with the client. The nurse should also consider the client's cultural background, preferences, and needs when selecting an interpreter.

Choice D reason: Using professional terminology when providing education prior to the procedure is not an action that the nurse should take. The nurse should use simple and clear language that the client can understand, and avoid using jargon, slang, or idioms that may confuse or offend the client. The nurse should also check the client's comprehension and ask for feedback throughout the communication.

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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)

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