Appropriate nursing interventions for a client with cachexia would include which of the following?
a. assisting in self-care activities to improve outward appearance
b. encouraging the client to eat any foods that are appealing
c. scheduling regular exercise time
d. providing a bland diet high in vitamins A and D
B
Nutritional alterations may result from secretion of cytokines that make the body digest muscle for energy instead of stored body fat, resulting in cachexia (malnutrition and protein wasting). If untreated, the cachexia may decrease the effectiveness of cancer treatment, increase the side effects of these treatments, or cause death. Nurses should assist clients to find a registered dietitian who is knowledgeable about cancer cachexia and ways to reduce its impact. Nurses can encourage clients to select foods that are appealing and to use appropriate nutritional supplements. Enteral or parenteral nutrition may be prescribed for these clients.
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A client had a colonoscopy and biopsy yesterday and calls the gastrointestinal clinic to report a spot of bright red blood on the toilet paper today. What response by the nurse is best?
a. Ask the client to call back if this happens again today. b. Instruct the client to go to the emergency department. c. Remind the client that a small amount of bleeding is possible. d. Tell the client to come in to the clinic this afternoon.
A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. What should the nurse document that the patient has?
a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis
After administering a CNS stimulant to a client being treated for respiratory depression, the nurse would continue to assess which of the following? Select all that apply
A) Blood pressure B) Pulse C) Respiratory rate D) Respiratory pattern E) Level of consciousness
Identify the nursing action that best prevents the introduction of air into a subclavian IV line when the nurse is changing the tubing on the IV solution
a. Keep the head of the bed elevated 45 de-grees. b. Have the client turn his head away from the insertion site. c. Encourage the client to do the Valsalva's maneuver during the procedure. d. Make sure the tubing on the old IV line is turned off before changing.