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
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","B","D","E"]
Explanation
A. Pain control options should be appropriate to the setting because different environments (e.g., home vs. hospital) may require different approaches to pain management, ensuring that the interventions align with the patient's needs and the context.
B. Timely and logical delivery of pain relief interventions is critical for effective pain management. Delays in treatment can lead to unnecessary suffering and complicate the overall management of the patient's condition.
C. Asking about pain only once a shift is insufficient for effective pain management. Pain can fluctuate frequently, especially in a client with cancer, so regular assessment is essential to address pain promptly.
D. Believing that pain is what the client reports it to be is fundamental to effective pain management. Pain is subjective, and clients' experiences and expressions of pain should be taken seriously to guide appropriate interventions.
E. A team approach is often the most effective for pain management, as it allows for a comprehensive plan that integrates multiple perspectives and disciplines, including nursing, medical, and possibly palliative care professionals, ensuring a holistic approach to managing pain.
Correct Answer is B
Explanation
A. Stomatitis is a common side effect of radiation therapy for oral cancer, and while it requires management, it is not immediately life-threatening.
B. Stridor indicates potential airway obstruction, which is a critical and urgent condition that requires immediate intervention, making it the greatest concern among the options presented.
C. Nausea is a typical side effect of cancer treatment but is usually manageable and not considered an immediate threat.
D. Xerostomia, or dry mouth, is another common side effect of radiation to the head and neck, but it is not as urgent as the risk of airway compromise indicated by stridor.