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
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Correct Answer is D
Explanation
The correct answer is Choice D because, "State health departments report selected STIs to the National Institutes of Health." This is the correct answer because state health departments are responsible for reporting selected STIs to the National Institutes of Health, which is an important regulation regarding STIs.
Choice A is wrong because, "Clients who have STIs are legally required to provide a list of sexual partners," is
not the correct answer because while clients who have STIs are strongly encouraged to provide a list of sexual partners for partner notification and treatment purposes, there is no legal requirement for them to do so.
Choice B is wrong because, "Congress mandates the requirements for STI reporting," is not the correct answer because STI reporting requirements are set by public health agencies, not by Congress.
Choice C is wrong because, "Nurses should withhold the name of the client who has an STI during partner notification," is not the correct answer because while nurses are required to maintain confidentiality of their clients, they are also obligated to report certain communicable diseases, including STIs, to public health authorities, who may need to conduct partner notification and treatment efforts.
Correct Answer is A
Explanation
Answer and explanation
The correct answer is Choice A because, "Conduct a survey to identify the community's need for hypertension screening." This is the correct answer because it is important to determine the need for hypertension screening in the community before implementing a health-screening program.
Choice B is wrong because, "Research best practices for treatment of hypertension," is not the correct answer because it is a step that comes after identifying the need for hypertension screening.
Choice C is wrong because, "Determine the number of clients referred for treatment of hypertension," is not the correct answer because it is a step that comes after hypertension screening has occurred.
Choice D is wrong because, "Apply for funding to conduct hypertension screening," is not the correct answer because it is a step that comes after identifying the need for hypertension screening and developing a plan for the health-screening program.
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