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NurseDive Free Nursing Practice Question
A nurse is reinforcing teaching with a client who is undergoing radiation therapy to the neck.
Which of the following instructions should the nurse include in the teaching?
A. Avoid exposing the neck to the cold.
Radiation therapy can cause increased sensitivity and dryness in the skin. Exposing the neck to cold temperatures may exacerbate these symptoms and potentially lead to discomfort or skin damage. Encourage the client to keep the neck covered and warm, especially when going outside in cold weather.
B. Eat three large meals each day.
While proper nutrition is important during radiation therapy, the specific instruction to eat three large meals each day is not necessarily applicable or beneficial. It is generally recommended to have a balanced and nutritious diet, which may include smaller, frequent meals or snacks if the client's appetite is affected.
C. Cleanse the neck by rubbing with a washcloth.
During radiation therapy, the skin in the treatment area can become sensitive and prone to irritation. Rubbing the neck vigorously with a washcloth can further irritate the skin. Instead, advise the client to gently cleanse the neck using a mild, non-irritating soap and patting the skin dry with a soft towel.
D. Limit fluid intake to 750 mL per day.
While radiation therapy can cause certain side effects, such as dry mouth or difficulty swallowing, it is generally not necessary to restrict fluid intake unless specifically advised by the healthcare provider. Adequate hydration is important for overall health and well-being, and the client should be encouraged to drink enough fluids unless instructed otherwise.
This question is an excerpt from Nurse Dive's nursing test bank - PN Comprehensive Predictor PN 2020 Proctored Exam. Take the full exam now
Full Explanation
Radiation therapy can cause increased sensitivity and dryness in the skin. Exposing the neck to cold temperatures may exacerbate these symptoms and potentially lead to discomfort or skin damage. Encourage the client to keep the neck covered and warm, especially when going outside in cold weather.
While proper nutrition is important during radiation therapy, the specific instruction to eat three large meals each day is not necessarily applicable or beneficial. It is generally recommended to have a balanced and nutritious diet, which may include smaller, frequent meals or snacks if the client's appetite is affected.
During radiation therapy, the skin in the treatment area can become sensitive and prone to irritation. Rubbing the neck vigorously with a washcloth can further irritate the skin. Instead, advise the client to gently cleanse the neck using a mild, non-irritating soap and patting the skin dry with a soft towel.
While radiation therapy can cause certain side effects, such as dry mouth or difficulty swallowing, it is generally not necessary to restrict fluid intake unless specifically advised by the healthcare provider. Adequate hydration is important for overall health and well-being, and the client should be encouraged to drink enough fluids unless instructed otherwise.
Similar Questions
A nurse is reviewing client confidentiality with a group of newly licensed nurses. Which of the following situations should the nurse include as an example of a breach in confidentiality?
A. A nurse discusses a client's postoperative complications during a shift report.
B. A social worker reads a client's chart as a follow-up to a requested consultation.
C. A facility risk manager includes information from a client's medical record in a written report.
D. A nurse tells the chaplain that a client has a new diagnosis of cancer.
In this scenario, the nurse disclosed sensitive medical information about the client's diagnosis to someone who is not directly involved in the client's care or treatment. This disclosure violates the client's right to privacy and confidentiality.
Full Explanation
In this scenario, the nurse disclosed sensitive medical information about the client's diagnosis to someone who is not directly involved in the client's care or treatment. This disclosure violates the client's right to privacy and confidentiality.
A nurse is caring for a 3-year-old child immediately following a tonic-clonic seizure. Which of the following actions should the nurse take?
A. Offer the child sips of clear fluids.
Seizures can be frightening for both the child and their caregivers. Providing a calm and soothing environment, offering comfort, and reassuring the child and their family can help alleviate anxiety and promote a sense of safety.
B. Administer an oral antiepileptic medication.
Administering medication or offering fluids should be determined based on the healthcare provider's orders and individual circumstances. It is essential to consult with the healthcare team for specific instructions regarding medications and fluid management after a seizure episode.
C. Check the child for oral injuries.
During a seizure, the child's muscles may contract forcefully, which can lead to accidental biting of the tongue or inner cheek. Inspecting the child's mouth for any signs of injury, such as bleeding or lacerations, is important for assessing and addressing immediate needs.
D. Place the child in a supine position.
Instead of placing the child in a supine position (flat on their back), it is recommended to position them on their side (recovery position) to help maintain an open airway and prevent aspiration in case of vomiting or secretions. This position also helps promote drainage of saliva or other fluids from the mouth.
Full Explanation
During a seizure, the child's muscles may contract forcefully, which can lead to accidental biting of the tongue or inner cheek. Inspecting the child's mouth for any signs of injury, such as bleeding or lacerations, is important for assessing and addressing immediate needs.
Instead of placing the child in a supine position (flat on their back), it is recommended to position them on their side (recovery position) to help maintain an open airway and prevent aspiration in case of vomiting or secretions. This position also helps promote drainage of saliva or other fluids from the mouth.
Seizures can be frightening for both the child and their caregivers. Providing a calm and soothing environment, offering comfort, and reassuring the child and their family can help alleviate anxiety and promote a sense of safety.
Administering medication or offering fluids should be determined based on the healthcare provider's orders and individual circumstances. It is essential to consult with the healthcare team for specific instructions regarding medications and fluid management after a seizure episode.
A nurse is reinforcing teaching with a client who is about to start using an albuterol metered-dose inhaler. Which of the following instructions should the nurse include in the teaching?
A. "Tilt your head forward while inhaling."
The correct technique for using a metered-dose inhaler does not involve tilting the head forward. Instead, the client should keep their head in a neutral position while using the inhaler. After inhaling the medication from the inhaler, it is recommended to hold the breath for about 10 seconds before exhaling. This allows the medication to be fully deposited in the lungs and absorbed effectively.
B. "Exhale immediately after inhaling."
The proper technique for using an albuterol metered-dose inhaler involves taking a slow and deep breath. The client should depress the canister once at the beginning of inhalation and continue to inhale slowly and deeply to ensure adequate medication delivery.
C. "Close your mouth around the mouthpiece."
Instruct the client to close their mouth tightly around the mouthpiece of the inhaler. This ensures that the medication is delivered directly into the lungs and minimizes the amount of medication escaping into the surrounding environment.
D. "Take three quick breaths while depressing the canister."
It is important for the nurse to demonstrate and observe the client's technique while using the inhaler to ensure proper administration.
Full Explanation
Instruct the client to close their mouth tightly around the mouthpiece of the inhaler. This ensures that the medication is delivered directly into the lungs and minimizes the amount of medication escaping into the surrounding environment.
The correct technique for using a metered-dose inhaler does not involve tilting the head forward.
Instead, the client should keep their head in a neutral position while using the inhaler. After inhaling the medication from the inhaler, it is recommended to hold the breath for about 10 seconds before exhaling. This allows the medication to be fully deposited in the lungs and absorbed effectively.
The proper technique for using an albuterol metered-dose inhaler involves taking a slow and deep breath. The client should depress the canister once at the beginning of inhalation and continue to inhale slowly and deeply to ensure adequate medication delivery.
It is important for the nurse to demonstrate and observe the client's technique while using the inhaler to ensure proper administration.