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Which of the following nursing actions will be most effective in improving oral intake for a patient with the nursing diagnosis of imbalanced nutrition: less than body requirements related to painful oral ulcers?
- A. Offer the patient frequent small snacks between meals.
- B. Assist the patient to choose favourite foods from the menu.
- C. Provide education about the importance of nutritional intake.
- D. Apply the ordered anaesthetic gel to oral lesions before meals.
Correct Answer: D
Rationale: Since the etiology of the patient's poor nutrition is the painful oral ulcers, the best intervention is to apply anaesthetic gel to the lesions before the patient eats. The other actions might be helpful for other patients with impaired nutrition, but would not be as helpful for this patient.
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The nurse is caring for a patient undergoing external radiation and has developed a dry desquamation of the skin in the treatment area. Which of the following patient statements indicates that the nurse's teaching about management of the skin reaction has been effective?
- A. I can buy some aloe gel to use on the area.
- B. I will expose the treatment area to a sun lamp daily.
- C. I can use ice packs to relieve itching in the treatment area.
- D. I will scrub the area with warm water to remove the scales.
Correct Answer: A
Rationale: Aloe gel and cream may be used on the radiated skin area. Ice and sunlamps may injure the skin. Treatment areas should be cleaned gently to avoid further injury.
The nurse is caring for a patient with cancer who has a nursing diagnosis of imbalanced nutrition: less than body requirements related to altered taste sensation. Which of the following nursing actions is most appropriate?
- A. Add strained baby meats to foods such as casseroles.
- B. Teach the patient about foods that are high in nutrition.
- C. Avoid giving the patient foods that are strongly disliked.
- D. Put extra spice in the foods that are served to the patient.
Correct Answer: C
Rationale: The patient will eat more if disliked foods are avoided and foods that the patient likes are included instead. Additional spice is not usually an effective way to enhance taste. Adding baby meats to foods will increase calorie and protein levels, but does not address the issue of taste. The patient's poor intake is not caused by a lack of information about nutrition.
The nurse is caring for a patient with metastatic renal cell carcinoma who is receiving interleukin-2 (IL-2) as an adjuvant therapy. Which of the following mechanisms of action should the nurse teach the patient about this therapy?
- A. It enhances immunological response to tumour cells.
- B. It stimulates malignant cells in the resting phase to enter mitosis.
- C. It prevents the bone marrow depression caused by chemotherapy.
- D. It protects normal cells from the harmful effects of chemotherapy.
Correct Answer: A
Rationale: IL-2 enhances the ability of the patient's own immune response to suppress tumour cells. IL-2 does not protect normal cells from damage caused by chemotherapy, stimulate malignant cells to enter mitosis, or prevent bone marrow depression.
External-beam radiation is planned for a patient with endometrial cancer. The nurse teaches the patient which of the following important measures to help prevent complications from the effects of the radiation?
- A. Test all stools for the presence of blood.
- B. Maintain a high-residue, high-fibre diet.
- C. Clean the perianal area carefully after every bowel movement
- D. Inspect the mouth and throat daily for the appearance of thrush.
Correct Answer: C
Rationale: Radiation to the abdomen will affect organs in the radiation path, such as the bowel, and cause frequent diarrhea. Careful cleaning of this area will help decrease the risk for skin breakdown and infection. Stools are likely to have occult blood from the inflammation associated with radiation, so routine testing of stools for blood is not indicated. Radiation to the abdomen will not cause stomatitis. A low-residue diet is recommended to avoid irritation of the bowel when patients receive abdominal radiation.
A patient with metastatic cancer of the colon experiences severe vomiting following each administration of chemotherapy. Which of the following interventions should the nurse implement?
- A. Teach about the importance of nutrition during treatment.
- B. Have the patient eat large meals when nausea is not present.
- C. Offer dry crackers and carbonated fluids during chemotherapy.
- D. Administer prescribed antiemetics 1 hour before the treatments.
Correct Answer: D
Rationale: Treatment with antiemetics before chemotherapy may help prevent nausea. Although nausea may lead to poor nutrition, there is no indication that the patient needs instruction about nutrition. The patient should eat small, frequent meals. Offering food and beverages during chemotherapy is likely to cause nausea.