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a home health nurse is caring for a client who has chemotherapy induced nausea that has been resistant to relief form pharmacological measures. which of the following interventions should the nurse initiate (select all that apply)?
- A. use seasonings to enhance the flavor of foods
- B. provide sips of room temperature ginger ale between meals
- C. maintain the head of theclients bed in an elevated position after eating
- D. offer 120 ml (4 oz.) of cold 2% milk as a meal replacement
- E. assist the client in using guided imagery
Correct Answer: D
Rationale: The correct answer is D: offer 120 ml (4 oz.) of cold 2% milk as a meal replacement. Cold milk can help soothe the stomach and provide some relief from nausea. It is important to offer a small amount like 120 ml to prevent overwhelming the digestive system.
A: Using seasonings may worsen nausea due to strong flavors.
B: Ginger ale can contain carbonation which may exacerbate nausea.
C: Elevating the head of the bed is more beneficial for GERD, not chemotherapy-induced nausea.
E: Guided imagery may be helpful for relaxation but may not directly address the nausea.
In summary, offering a small amount of cold milk is the most appropriate intervention as it can help provide relief without exacerbating the nausea.
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a community health nurse is working with a group of homeless veterans who have posttraumatic stress disorder. which of the following interventions should the nurse implement?
- A. provide coffee and snacks during the meetings
- B. avoid discussing the traumatic events experienced by the veterans
- C. change the meetings sites frequently
- D. teach the clients to practice deep breathing exercises
Correct Answer: C
Rationale: The correct answer is C: change the meeting sites frequently. This intervention is important for individuals with PTSD as it helps prevent triggers associated with specific locations, reducing anxiety and potential retraumatization. Providing coffee and snacks (A) may be helpful, but changing meeting sites is a more crucial step. Avoiding discussing traumatic events (B) may hinder the veterans' healing process by avoiding necessary therapeutic conversations. Teaching deep breathing exercises (D) can be beneficial but may not address the core issues related to PTSD.
a nurse is conducting a community assessment. which of the following information should the nurse include as part of the windshield survey?
- A. demographic data
- B. mortality rate
- C. informant interviews
- D. housing quality
Correct Answer: A
Rationale: The correct answer is A: demographic data. In a windshield survey, the nurse observes the community from a car to gather data. Demographic data, such as age, gender, ethnicity, and socioeconomic status, provides a foundational understanding of the community's composition and needs. Mortality rate (B) and housing quality (D) are important but are not typically assessed through a windshield survey. Informant interviews (C) involve direct communication and are not part of a windshield survey method.
During a home health visit a school age child who has muscular dystrophy confidesin the nurse that he was struck by his parents. which of the following actions should the nurse take first?
- A. report the incident to local authorities
- B. check the child for injuries
- C. refer the parent to a social service agency
- D. enroll the parent in anger management classes.
Correct Answer: A
Rationale: The correct answer is A: report the incident to local authorities. The nurse's first priority is to ensure the safety and well-being of the child. Reporting to local authorities is crucial to protect the child from further harm and to initiate an investigation. Checking for injuries (B) is important but secondary to ensuring the child's safety. Referring the parent to a social service agency (C) or enrolling them in anger management classes (D) does not address the immediate safety concerns of the child. In this situation, immediate action through reporting to authorities is the most appropriate course of action.
a nurse is counseling a client who is to undergo enzyme linked immunosorbent assay testing for hiv. which of the following information should the nurse include?
- A. the test monitors progression of the disease
- B. the test measures antibodies to the virus
- C. the test results are accurate 24 hr. after exposure to the virus
- D. a positive result requires initiating immunoglobulin administration
Correct Answer: B
Rationale: The correct answer is B: the test measures antibodies to the virus. In enzyme linked immunosorbent assay (ELISA) testing for HIV, antibodies produced by the body in response to the virus are detected. This helps in diagnosing HIV infection. Monitoring disease progression (choice A) requires other tests like viral load testing. Test results are not accurate within 24 hours of exposure (choice C) as it takes time for antibodies to develop. Initiating immunoglobulin administration (choice D) is not necessary for all positive results and depends on the individual's condition.
which of the following .........should the nurse include
- A. .............should be placed beside the child’s bed
- B. house hold contacts will receive prophylactic antibiotics
- C. transmission will be emitted because of herd immunity
- D. the child is most contagious after the rash develops
Correct Answer: C
Rationale: The correct answer is C. The nurse should include information about transmission being limited due to herd immunity. This is important because herd immunity occurs when a large portion of the community becomes immune to a disease, reducing the chances of transmission even to those who are not immune. This information is crucial for preventing the spread of infectious diseases within a community.
Choice A is incorrect as it does not provide relevant information about disease transmission or prevention. Choice B is incorrect as it focuses on treatment rather than prevention of transmission. Choice D is incorrect as it provides inaccurate information about the timing of contagion.