The nurse is caring for a client diagnosed with cancer who is experiencing a decreased nutritional intake due to painful oral lesions. Which intervention would the nurse include in the plan of care?

Encourage client to rinse the mouth twice a day with mouthwash

Encourage client to perform mouth care before and after every meal

Offer the client 3 meals per day with a snack at bedtime

Assess the client's oral pain level once a shift

Answer and Explanation

The Correct Answer is B

A. Rinsing the mouth with mouthwash is not sufficient for managing oral lesions, and some mouthwashes may contain alcohol that can further irritate the lesions; therefore, this intervention is inadequate.
B. Performing mouth care before and after every meal can help minimize discomfort, remove debris, and maintain oral hygiene, which is crucial for someone with painful oral lesions to encourage better nutritional intake.
C. Offering three meals with a bedtime snack may not be effective if the client is unable to eat comfortably; focusing on smaller, more frequent meals or nutrient-dense options may be more beneficial.
D. While assessing oral pain is important, it should occur more frequently than once per shift to ensure ongoing management and adjustment of care based on the client’s comfort and needs.

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Correct Answer is ["A","D","E"]

Explanation

A. Encouraging the use of an incentive spirometer helps prevent respiratory complications and promotes lung expansion, thereby reducing the risk of infection, particularly pneumonia.
B. While early mobilization is important for recovery, assisting the client out of bed on post-operative day 1 may not be appropriate depending on the patient's condition; this option is not directly related to infection prevention.
C. Repositioning every four hours is important for pressure ulcer prevention but does not directly impact infection risk; more frequent repositioning may be necessary to ensure adequate skin integrity and circulation.
D. Utilizing aseptic technique while changing the dressing is crucial for preventing infection at the surgical site, making this a vital intervention.
E. Maintaining TEDS (thromboembolic deterrent stockings) and SCDs (sequential compression devices) helps prevent deep vein thrombosis (DVT) and improves circulation, which can indirectly reduce infection risk by promoting better blood flow.

A. Human papilloma virus (HPV) vaccination in teenagers B. BRCA1 and BRCA2 testing when the client's mother and sister died of ovarian cancer C. Annual mammogram for women over 40 years D. Rehabilitation exercises for those who received chemotherapy

Correct Answer is A

Explanation

A. The HPV vaccination is a form of primary prevention as it aims to prevent the initial occurrence of cervical cancer by protecting against the human papillomavirus, which is a major risk factor for this cancer.
B. BRCA1 and BRCA2 testing is a form of genetic testing used for risk assessment rather than prevention; it helps identify individuals at high risk for breast and ovarian cancers but does not prevent cancer itself.
C. Annual mammograms are a secondary prevention measure aimed at early detection of breast cancer rather than preventing the disease from occurring, as they help identify cancer in its early stages.
D. Rehabilitation exercises post-chemotherapy are supportive measures for patients undergoing treatment; they do not constitute primary prevention, which focuses on measures taken before cancer develops.

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The nurse is caring for a client diagnosed with cancer who is experiencing a decreased nutritional intake due to painful oral lesions. Which intervention would the nurse include in the plan of care?

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The nurse is caring for a client diagnosed with cancer who is experiencing a decreased nutritional intake due to painful oral lesions. Which intervention would the nurse include in the plan of care?