A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck.
Which of the following instructions should the nurse include in the teaching?
Avoid exposing the neck to the cold.
Eat three large meals each day.
Cleanse the neck by rubbing with a washcloth.
Limit fluid intake to 750 mL per day.
The Correct Answer is A
Radiation therapy can cause increased sensitivity and dryness in the skin. Exposing the neck to cold temperatures may exacerbate these symptoms and potentially lead to discomfort or skin damage. Encourage the client to keep the neck covered and warm, especially when going outside in cold weather.
While proper nutrition is important during radiation therapy, the specific instruction to eat three large meals each day is not necessarily applicable or beneficial. It is generally recommended to have a balanced and nutritious diet, which may include smaller, frequent meals or snacks if the client's appetite is affected.
During radiation therapy, the skin in the treatment area can become sensitive and prone to irritation. Rubbing the neck vigorously with a washcloth can further irritate the skin. Instead, advise the client to gently cleanse the neck using a mild, non-irritating soap and patting the skin dry with a soft towel.
While radiation therapy can cause certain side effects, such as dry mouth or difficulty swallowing, it is generally not necessary to restrict fluid intake unless specifically advised by the healthcare provider. Adequate hydration is important for overall health and well-being, and the client should be encouraged to drink enough fluids unless instructed otherwise.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When caring for a client with paranoid schizophrenia who has delusions or beliefs that are not based in reality, it is important to respond in a therapeutic and empathetic manner. Acknowledging the client's fear and validating their experience can help establish trust and promote open communication.
The response "This must be very frightening for you. Let's talk more about it" demonstrates empathy and a willingness to engage in further discussion, allowing the client to express their concerns and facilitating a therapeutic relationship.
Correct Answer is A
Explanation
Hyperactive bowel sounds are bowel sounds that are louder and more frequent than normal. They may be heard as high-pitched rushing or tinkling sounds that occur irregularly at a rate greater than 5-6 sounds per minute. They are often associated with increased intestinal motility, such as diarrhea, gastroenteritis, or early bowel obstruction.
Option b is incorrect because hyperactive bowel sounds are not typically associated with a paralytic ileus, which is a condition where the bowel stops working and there is a lack of bowel sounds.
Option c is incorrect because hyperactive bowel sounds indicate increased motility, not decreased motility.
Option d is incorrect because soft bowel sounds at a rate of 1/min are considered hypoactive bowel sounds, which can be a sign of decreased intestinal motility, as seen in constipation or postoperative ileus.
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