A nurse discusses the self-care guidelines to minimize the side effects of radiation on the skin. Which self-care instructions can the nurse provide the client receiving radiation? [Select all that apply.]
Use a razor to shave the hair in the treated area.
Wash treated area gently with lukewarm water and mild soap.
Purchase aloe approved skin-care products
Wear loose-fitting, soft clothing over the treated skin.
Sun tan the affected area for no more than 30 minutes a day
Correct Answer : B,C,D
A) Use a razor to shave the hair in the treated area:
Shaving the treated area with a razor is not recommended during radiation therapy. The skin in the treated area becomes sensitive and fragile, so shaving could cause irritation, cuts, or abrasions. Instead, clients are usually advised to use electric razors or avoid shaving the area altogether. This instruction should not be followed to minimize the risk of injury.
B) Wash treated area gently with lukewarm water and mild soap:
This is a key self-care instruction for clients receiving radiation. Gentle cleansing with lukewarm water and mild soap helps to avoid further irritation to the skin, which can become dry and sensitive during radiation therapy. The treated area should not be scrubbed or rubbed, as this can cause damage to the skin, exacerbate dryness, or cause skin breakdown. This guideline is appropriate and should be followed.
C) Purchase aloe-approved skin-care products:
Using aloe vera or skin-care products approved for use during radiation therapy can help soothe and moisturize the skin, which often becomes dry, irritated, or sunburned from radiation. It is important to use products that are specifically designed for use during radiation to avoid any potential irritants or allergens. Aloe-based products or products recommended by the healthcare provider can provide relief and reduce side effects.
D) Wear loose-fitting, soft clothing over the treated skin:
Wearing loose-fitting, soft clothing is a crucial self-care recommendation for clients undergoing radiation. Tight or rough fabrics can irritate the sensitive skin, potentially leading to discomfort or skin breakdown. Soft fabrics like cotton are ideal, as they allow the skin to breathe and help avoid further friction or pressure on the treated area. This is an important aspect of skin protection during radiation therapy.
E) Sun tan the affected area for no more than 30 minutes a day:
Sun tanning or exposing the treated skin to direct sunlight is strictly forbidden during and after radiation therapy. The skin in the treated area is much more sensitive to UV radiation and can burn easily, even with minimal sun exposure. It can increase the risk of skin damage and delayed healing. The client should be advised to avoid direct sun exposure entirely and to wear protective clothing and sunscreen if they must be outdoors.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A) Inability to void:
While urinary retention or difficulties with voiding can occur in ALS patients due to weakened muscles affecting the bladder, it is not the most immediate or life-threatening symptom that requires urgent attention. ALS primarily affects motor neurons and the voluntary muscles, and while autonomic dysfunction can lead to bladder or bowel issues, these are typically not the first concern in the acute phase of ALS unless they are severe.
B) Unable to eat without thickening meals:
Dysphagia (difficulty swallowing) is a common symptom in ALS, especially as the disease progresses and affects the muscles of the throat. While this symptom is important to address, it is manageable with interventions like speech therapy, modified diets, and thickened liquids
C) Loss of function in the lower extremity:
Loss of function in the lower extremities is a hallmark symptom of ALS as the disease progresses, but it is not an acute or life-threatening situation on its own. ALS leads to gradual muscle weakness and atrophy, particularly affecting voluntary motor functions.
D) Difficulty breathing:
As ALS progresses, respiratory muscles, including the diaphragm and intercostal muscles, weaken, which can lead to respiratory failure. The inability to breathe adequately can be life-threatening and may require interventions like mechanical ventilation, non-invasive positive pressure ventilation (BiPAP), or even a tracheostomy.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
|
Assessment findings |
Expected Findings |
Findings to be reported to provider |
|
Barrel chest |
✔️ |
|
|
Increased fatigue |
✔️ |
|
|
Respiratory rate 40bpm |
✔️ |
|
|
Thin appearance |
✔️ |
Barrel chest: Expected Finding
Increased fatigue: Finding to be reported to the provider
Respiratory rate 40 bpm: Finding to be reported to the provider
Thin appearance: Expected Finding
Rationales:
Barrel chest – Expected Finding:
A barrel chest is a common physical finding in clients with chronic obstructive pulmonary disease (COPD), especially emphysema. It results from hyperinflation of the lungs over time, altering the shape of the chest wall.
Increased fatigue – Finding to be reported to the provider:
While COPD clients often experience fatigue, a sudden or unusual increase in fatigue may indicate worsening respiratory function or exacerbation of the disease. This finding requires further assessment and possible intervention to prevent complications.
Respiratory rate 40 bpm – Finding to be reported to the provider:
A respiratory rate of 40 bpm indicates significant tachypnea and respiratory distress. This finding, coupled with accessory muscle use, suggests the client may be experiencing an acute exacerbation of COPD or impending respiratory failure, which requires immediate provider notification.
Thin appearance – Expected Finding:
Clients with COPD often have a thin or cachectic appearance due to increased energy expenditure for breathing and reduced caloric intake. This is a typical finding in advanced COPD and does not require urgent reporting unless accompanied by other concerning symptoms.
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