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. High-protein foods are not typically irritating after an esophagogastrectomy and are essential for healing and maintaining nutritional status. Clients should be encouraged to eat balanced meals with adequate protein.
B. Clients recovering from an esophagogastrectomy should avoid snacking between meals to prevent dumping syndrome, a common complication where food moves too quickly from the stomach to the small intestine. Instead, small, frequent meals should be consumed.
C. While pureed foods may be part of the immediate post-operative diet, the long-term goal is to gradually reintroduce solid foods, following the physician's dietary recommendations. A pureed diet is not necessarily required long-term.
D. Lying flat after meals increases the risk of reflux, which can be particularly harmful to clients recovering from esophageal surgery. Clients should be advised to stay upright after eating to aid digestion and prevent reflux.
Correct Answer is C
Explanation
A. Assessing the degree of upper body vasculature may provide some information, but it does not directly address the client's current symptoms or vital status.
B. Measuring arm circumference and evaluating the degree of edema are important for understanding the extent of swelling but do not assess the client’s hemodynamic stability or respiratory status.
C. Blood pressure and heart rate are critical assessments in this scenario, especially considering the client’s dyspnea and upper body edema. Changes in these vital signs can indicate potential respiratory distress, compromised cardiac function, or anaphylaxis, which requires immediate intervention.
D. While assessing peripheral sensation and movement is important for overall neurological function, it is not a priority in this context compared to assessing vital signs that can directly affect the client’s stability.