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. A history of Roux-en-Y gastric bypass surgery is not a direct risk factor for colorectal cancer; in some cases, it may reduce risk due to weight loss and dietary changes.
B. A high fiber, low fat diet is considered protective against colorectal cancer rather than a risk factor.
C. A personal history of inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, significantly increases the risk for developing colorectal cancer due to chronic inflammation and cellular changes in the colon.
D. Having a distant relative with colorectal cancer may increase risk, but the personal history of inflammatory bowel disease is a stronger risk factor warranting emphasis in teaching.
Correct Answer is C
Explanation
A. Limiting visits by family members and friends is not necessary for managing ascites and could hinder the client's emotional support.
B. While amylase and lipase are important in assessing pancreatic function, they are not directly relevant to ascites management or liver cancer.
C. An abdominal assessment including abdominal girth is crucial for monitoring ascites, as changes in girth can indicate fluid accumulation or changes in the client's condition.
D. Continuous cardiac monitoring is not typically indicated for clients with liver cancer experiencing ascites unless there are specific cardiac concerns.