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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: The test does not monitor the progression of the disease, as it only detects the presence of antibodies to HIV, not the amount of virus or the damage to the immune system. Other tests, such as viral load and CD4 count, are used to monitor the progression of HIV infection and the response to treatment.
Choice B reason: The test measures antibodies to the virus, which are produced by the immune system in response to HIV infection. The test is used to screen for HIV infection and to confirm the diagnosis. A positive result indicates that the person has been exposed to HIV and has developed antibodies to the virus.
Choice C reason: The test results are not accurate 24 hours after exposure to the virus, as it takes time for the body to produce enough antibodies to be detected by the test. The window period, which is the time between exposure to HIV and a positive test result, varies from person to person, but it can range from 3 weeks to 3 months. Therefore, a negative result does not necessarily rule out HIV infection, and a repeat test may be needed after the window period.
Choice D reason: A positive result does not require initiating immunoglobulin administration, as immunoglobulin is not a treatment for HIV infection. Immunoglobulin is a preparation of antibodies that can provide temporary protection against some infections, but it does not affect HIV. A positive result requires further confirmation by a more specific test, such as the Western blot, and referral to a specialist for treatment and counseling.
Correct Answer is D
Explanation
Choice A reason: A consultant is someone who provides expert advice or guidance on a specific topic or problem. A nurse case manager may act as a consultant when collaborating with other health care professionals or community agencies, but not when arranging for the delivery of medical equipment to the client's home.
Choice B reason: A systems allocator is someone who distributes or allocates resources or services within a system or organization. A nurse case manager may act as a systems allocator when managing the cost and quality of care for a client, but not when arranging for the delivery of medical equipment to the client's home.
Choice C reason: An advocate is someone who supports or defends the rights or interests of another person or group. A nurse case manager may act as an advocate when promoting the client's autonomy, dignity, and well-being, but not when arranging for the delivery of medical equipment to the client's home.
Choice D reason: A coordinator is someone who organizes or facilitates the activities or interactions of different people or groups. A nurse case manager acts as a coordinator when arranging for the delivery of medical equipment to the client's home, as this involves coordinating with the client, the provider, the supplier, and the insurance company.
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