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 : A,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.
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 C
Explanation
The correct answer is Choice C because, "Immunizing the clients against influenza." Older adults are at higher risk of developing serious complications from the flu, including pneumonia, and are more likely to be hospitalized due to the flu.
Immunizing the clients against influenza is an important health promotion strategy to reduce this risk.
Choice A is wrong because, "Scheduling annual dental examinations for the clients," is not the correct answer because although oral health is important, it is not the priority health promotion strategy for older adults.
Choice B is wrong because, "Encouraging the clients to exercise regularly," is not the correct answer because although exercise is important for older adults, it is not the priority health promotion strategy for older adults living in an assisted living facility.
Choice D is wrong because, "Providing the clients with a low-fat diet," is not the correct answer because although a healthy diet is important, it is not the priority health promotion strategy for older adults living in an assisted living facility.
Correct Answer is D
Explanation
The correct answer is choice D, Scratching or piercing the skin. This behavior is known as self-harm or non-suicidal self-injury, and it is a maladaptive coping mechanism that can result from unmanaged stress or negative emotions. The nurse should identify this behavior as a priority and provide resources for the adolescent to seek professional help, including counseling or therapy.
Choice A, staying up all night playing online video games, can be a form of procrastination or avoidance but does not necessarily indicate a need for immediate intervention.
Choice B, listening to loud music for several hours, can also be a coping mechanism, but it is not necessarily harmful or maladaptive.
Choice C, talking about others on social media, maybe a negative behavior, but it does not indicate a need for immediate intervention unless it leads to cyberbullying or harassment.
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