The home health nurse in Wyoming gives instruction to an 80-year-old patient in the prevention of hypothermia.

Which information should the nurse include? (Select all that apply.)

Rationale for correct condition: Mucositis is a common side effect of chemotherapy that causes inflammation and soreness in the mouth. The client reports mouth soreness and dry mucous membranes, consistent with mucositis. The presence of mild erythema on the oral mucosa also supports this diagnosis. Chemotherapy drugs such as vincristine and anthracycline are known to cause mucositis. Addressing mucositis early is crucial for maintaining the client’s nutrition and hydration.

Rationale for actions: Providing a soft sponge toothbrush helps maintain oral hygiene without causing further irritation. Maintaining the client’s diet ensures adequate nutrition, which is essential for healing mucositis. Pad the siderails of the bed is unnecessary in this scenario, as there's no indication of seizure risk. Requesting an antiemetic is irrelevant since the client has no significant nausea or vomiting.

Rationale for parameters: Monitoring weight loss helps assess the client’s nutritional status and the effectiveness of dietary interventions. Tracking intake and output ensures the client is adequately hydrated and that oral intake is sufficient. Edema monitoring is unnecessary, as there's no sign of fluid retention. Steatorrhea is not relevant in this context, as there's no indication of fat malabsorption.

Rationale for incorrect conditions: Diarrhea is not indicated as the client’s primary complaint is mouth soreness, not gastrointestinal upset. Angioedema is characterized by swelling and is not observed in the client. Seizures are not relevant here, as the client shows no neurological signs suggestive of seizure activity.

Choice A rationale
Inserting an indwelling catheter is not recommended for immunosuppressed clients due to the increased risk of infection. Minimizing invasive procedures is critical in these patients.
Choice B rationale
Providing fresh fruit is not advisable for immunosuppressed clients, as raw fruits and vegetables can harbor bacteria and increase the risk of infection. Cooked foods are safer options.
Choice C rationale
Taking the client's temperature once per shift is insufficient for monitoring infection in immunosuppressed clients. More frequent temperature monitoring is necessary to detect early signs of infection.
Choice D rationale
Limiting the number of health care workers entering the room is essential for reducing the risk of infections in immunosuppressed clients, as it minimizes exposure to potential pathogens.