A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia.
Which of the following actions should the nurse take?
Encourage the client to drink low-protein supplements.
Serve the client's largest meal in the evening.
Provide the client with cold foods rather than hot foods.
Tell the client to drink two glasses of water with meals.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale:
Encouraging the client to drink low-protein supplements is not the best action. Protein is essential for tissue repair and healing, especially when the body is under stress, such as during radiation therapy. Therefore, it would be more beneficial to encourage high-protein foods and supplements.
Choice B rationale:
Serving the client’s largest meal in the evening is not the most effective strategy. Radiation therapy can cause nausea and vomiting, which are often worse later in the day. Therefore, it might be more beneficial to serve a larger meal earlier in the day when the client is more likely to tolerate it.
Choice C rationale:
Providing the client with cold foods rather than hot foods is the correct action. Hot foods can often exacerbate feelings of nausea, which are common side effects of radiation therapy. Cold foods are generally better tolerated.
Choice D rationale:
Telling the client to drink two glasses of water with meals is not the best advice. While hydration is important, drinking large amounts of fluid with meals can contribute to early satiety, which can further decrease the client’s food intake. It might be more beneficial to encourage the client to drink fluids between meals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
An altered level of consciousness is a common finding in clients with Alzheimer's disease. This may range from mild confusion to severe cognitive impairment. It is caused by the degeneration of brain cells and affects memory, thinking, and behavior.
Choice B rationale:
Rapid mood swings are not specific to Alzheimer's disease. While mood changes can occur, they are not typically characterized by rapid swings. Mood disturbances may include depression, apathy, or irritability, but these symptoms are not unique to Alzheimer's disease.
Choice C rationale:
Excessive motor activity is not a typical finding in clients with Alzheimer's disease. Instead, clients often experience a decline in motor skills and coordination as the disease progresses. Restlessness or agitation might occur, but excessive motor activity is not a characteristic feature.
Choice D rationale:
Failure to recognize familiar objects, people, or places is a common symptom of Alzheimer's disease. This is due to the damage and loss of nerve cells in the brain. As the disease advances, clients may have difficulty recognizing even close family members or their own reflection in the mirror.
Correct Answer is B
Explanation
The correct answer is Choice b: New onset of hearing loss.
Gentamicin, a potent aminoglycoside antibiotic, is renowned for its propensity to cause ototoxicity, particularly manifesting as new-onset hearing loss. Ototoxicity refers to damage to the inner ear structures responsible for hearing and balance, primarily the cochlea and vestibular apparatus. The mechanism of gentamicin-induced ototoxicity involves its accumulation in the endolymphatic fluid of the inner ear, leading to direct toxicity to the sensory hair cells and subsequent hearing impairment.
Manifestations of gentamicin-induced ototoxicity can vary, ranging from subtle high-frequency hearing loss to profound sensorineural deafness. Patients may experience tinnitus (ringing in the ears), difficulty hearing in noisy environments, and imbalance or vertigo. Notably, gentamicin-induced hearing loss is often irreversible and may progress even after discontinuation of the medication.
Now, let's delve into the rationales for the other choices:
Choice a: Hypotension Gentamicin administration is not typically associated with hypotension. However, systemic side effects such as nephrotoxicity and neurotoxicity can occur, particularly with prolonged or high-dose therapy. Nephrotoxicity may manifest as acute kidney injury, characterized by a rise in serum creatinine and blood urea nitrogen levels, oliguria, and fluid-electrolyte imbalances. Neurotoxicity, on the other hand, can lead to symptoms like muscle weakness, paresthesia, and confusion. Monitoring of blood pressure is essential in patients receiving gentamicin, but hypotension is not a direct adverse effect of the medication.
Choice c: Hyperthermia Gentamicin therapy is aimed at treating bacterial infections, such as pyelonephritis, and does not typically induce hyperthermia. Pyelonephritis itself is associated with fever, chills, and flank pain due to the inflammatory response to the urinary tract infection. Administration of gentamicin aims to eradicate the causative bacteria and resolve the underlying infection, which should, in turn, alleviate fever. However, persistent or worsening fever despite antibiotic therapy may indicate treatment failure or the presence of complicating factors, warranting further evaluation and management.
Choice d: Slurred speech Slurred speech is not a recognized adverse effect of gentamicin. Instead, it may suggest central nervous system involvement, such as cerebrovascular accidents (strokes), intoxication, or neurological disorders affecting speech production. Gentamicin primarily exerts its toxic effects on the inner ear structures, leading to auditory dysfunction rather than impairments in speech articulation. Therefore, the presence of slurred speech would prompt an assessment for alternative etiologies unrelated to gentamicin therapy.
In conclusion, while gentamicin is an effective antibiotic for treating infections, it carries the risk of ototoxicity, particularly manifested as new-onset hearing loss. Careful monitoring for this adverse effect is crucial to promptly identify and manage potential complications.
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