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 B
Explanation
A. Washing the skin with water is generally acceptable, but applying scented lotion is not recommended as it may irritate the skin or interfere with treatment; only specific products as advised by the healthcare provider should be used.
B. Skin treatment markings are important for ensuring correct targeting of radiation during therapy and should remain intact for the duration of treatment to avoid misalignment.
C. While some precautions may be necessary, limiting time with others at home is not typically a requirement for external radiation, as it does not make the client radioactive.
D. Skin damage can occur from radiation treatment, and any changes should be reported to the healthcare provider, as monitoring and managing side effects is important for the patient's overall care.
Correct Answer is A
Explanation
A. The initial assessment describes a state of confusion where the patient is awake but experiencing forgetfulness and difficulty following commands. The subsequent assessment indicates lethargy, as the patient is now sleepy and has slow responses, which aligns with the definitions of confusion and lethargy.
B. While confusion is present in the first assessment, stupor describes a state of near-unconsciousness, which does not match the second assessment.
C. Although lethargy is appropriate for the second assessment, obtunded refers to a state where the patient is less aware and has difficulty arousing, which is not accurately described here.
D. The first assessment indicates confusion, but the patient is not fully conscious as described in the second assessment, which does not align with this option.