A nurse is observing an assistive personnel (AP) take a client's tympanic temperature. Which of the following actions should the nurse identify as an indication that the AP understands how to perform the procedure?

Choice A Reason:

Loose stools are not a typical side effect of radiation therapy for throat cancer. Gastrointestinal side effects may occur, but they are more likely to involve symptoms such as nausea, diarrhea, or difficulty swallowing.

Choice B Reason:

Bladder infection is not directly related to radiation therapy for throat cancer. The side effects of radiation therapy typically pertain to the area being treated, such as the throat and surrounding tissues.

Choice C Reason:

Increased appetite is also not a common side effect of radiation therapy. Many clients may experience a decreased appetite or difficulty eating due to the side effects of radiation, such as mucositis (inflammation of the mouth and throat) or dysgeusia.

Choice D Reason:

Loss of taste is correct . Clients who receive external radiation therapy for throat cancer can experience various side effects due to the radiation's impact on the surrounding tissues. One common side effect is a loss of taste or changes in taste perception, which is known as dysgeusia. This occurs because radiation can damage taste buds and the salivary glands, leading to alterations in taste sensation. Clients may describe a metallic or bitter taste in their mouths or have difficulty tasting certain foods.

Choice A Reason:

Maintaining the client in high-Fowler's position is a correct action. Keeping the client in a high-Fowler's position (sitting up with the head of the bed elevated) can help improve lung expansion and ease breathing for clients with heart failure and respiratory distress.

Choice B Reason:

Instructing the client to cough every 4 hr. is not directly addressing the underlying issue of fluid accumulation and respiratory distress associated with heart failure. Coughing alone may not be sufficient to alleviate these symptoms.

Choice C Reason:

Increasing the client's intake of oral fluids is generally not recommended without considering the client's overall fluid status. In heart failure, there is often a need to restrict fluid intake to prevent fluid overload and worsening of symptoms. Increasing oral fluids should be done cautiously and under the guidance of the healthcare provider.

Choice D Reason:

Encouraging the client to ambulate to loosen secretions. While ambulation can be beneficial for some clients to improve overall circulation and prevent complications, it may not be the primary intervention in this case. The client's primary issue is likely related to pulmonary congestion due to heart failure, and they may be too short of breath to ambulate effectively.