The nurse is teaching a client with cancer about skincare for the portal site receiving external beam radiation. Which client action regarding skin care indicates a need for further teaching?
Applies prescribed lotions to the radiation site.
Washes the radiation site with antibacterial soap and water.
Wears clothing to cover the radiation site.
Dries the area with patting motions after taking a shower.
The Correct Answer is B
Choice A rationale:
Applying prescribed lotions to the radiation site is generally a recommended part of skin care during radiation therapy, as it helps keep the skin moisturized and reduces irritation.
Choice B rationale:
Washing the radiation site with antibacterial soap and water is not recommended. Clients undergoing radiation therapy are typically advised to use gentle, mild soaps and to avoid scrubbing or using harsh cleansers on the treated area. Antibacterial soap may be too harsh and could lead to skin irritation.
Choice C rationale:
Wearing clothing to cover the radiation site is a good practice to protect the area from sun exposure and potential irritation.
Choice D rationale:
Drying the area with patting motions after taking a shower is the correct way to dry the radiation site, as it minimizes friction and reduces the risk of skin damage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A five-pound weight gain in a client taking lithium carbonate is significant. however, the timeframe of the weightgain is to be known.Choice B rationale:
Nausea and vomiting are known side effects of lithium that should be reported as they can cause electrolyte imbalance.
Choice C rationale:
Short-term memory loss is a potential side effect of lithium, but it may not require immediate reporting unless it significantly affects the client's daily functioning or is associated with other concerning symptoms.
Choice D rationale:
A depressed affect is a symptom that should be addressed as part of the client's ongoing psychiatric care, but it may not warrant immediate reporting unless it is severe and requires a change in the treatment plan. The priority in this case is the potential lithium toxicity indicated by the weight gain.
Correct Answer is C
Explanation
Choice A rationale:
While completing a thorough room search to remove potential self-harming objects is important, it should follow the immediate need for monitoring and intervention.
Choice B rationale:
Providing time alone in the client's room may not be appropriate when the client is exhibiting signs of distress and increased risk.
Choice C rationale:
Closely monitoring the client and having staff intervene as needed (Choice C) is the most important intervention in this situation. Clients with a history of self-mutilation who display signs of increased tension and agitation may be at higher risk for engaging in self-harming behaviors. Close observation and intervention can help prevent self-harm and ensure the client's safety.
Choice D rationale:
Giving firm, consistent expectations is important in the overall care plan but may not be effective in acute situations where immediate monitoring and intervention are required.
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