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 C
Explanation
A. While no episodes of diarrhea may be beneficial, it is not a direct indicator of the effectiveness of ondansetron, which is used primarily to prevent nausea and vomiting.
B. Maintaining a normal hemoglobin level is not an expected outcome related to ondansetron, as it does not influence blood counts.
C. The ability to tolerate oral fluid intake indicates that the client is managing nausea effectively, demonstrating that ondansetron is working as intended.
D. Hair loss is a common side effect of many chemotherapeutic agents, and ondansetron does not affect this outcome. Therefore, it is not an appropriate indicator of the medication's effectiveness.
Correct Answer is B
Explanation
A. This statement is accurate as Mohs surgery involves examining each layer of skin for cancer cells before proceeding with further removal.
B. The client indicates a misunderstanding; Mohs surgery does not typically involve a needle biopsy of the lymph node at the time of the procedure, as it focuses on the local removal of skin cancer.
C. This statement is correct as the goal of Mohs surgery is to remove the cancer while preserving as much healthy tissue as possible.
D. This statement is also true as Mohs surgery is designed to minimize healthy tissue removal, often resulting in better cosmetic outcomes