A male patient who had surgery 2 days ago for head and neck cancer is about to make his first attempt to ambulate outside his room. The nurse notes that he is steady on his feet and that his vision was unaffected by the surgery. Which of the following nursing interventions would be appropriate?

Correct Answer: C

Rationale: The rationale for the correct answer and incorrect choices is as follows: **C: Accompany the patient for his walk** This is the correct choice because, despite the patient appearing steady and having unaffected vision, he is still in the early postoperative phase (only two days after head and neck cancer surgery). Post-surgical patients, especially those recovering from procedures involving major anatomical areas like the head and neck, can experience sudden dizziness, fatigue, or hypotension due to anesthesia residuals, pain medications, or underlying medical conditions. The presence of a nurse ensures immediate assistance if the patient becomes weak, loses balance, or experiences complications. Additionally, the nurse can assess the patient’s endurance, gait stability, and any signs of distress during ambulation, providing real-time guidance and reassurance. **A: Encourage the patient to walk in the hall alone** This is incorrect because, although the patient may seem stable, early postoperative ambulation carries inherent risks, such as falls or syncopal episodes, which could lead to serious injury—particularly in a patient recovering from head and neck surgery. Allowing independent ambulation without supervision disregards the potential for unforeseen complications, such as orthostatic hypotension or sudden weakness. A fall could disrupt surgical sites, cause bleeding, or delay recovery. Nursing best practice involves monitoring high-risk patients during initial mobilization, even if they appear capable. **B: Discourage the patient from walking in the hall for a few more days** This is incorrect because early ambulation is generally encouraged in postoperative care to prevent complications like deep vein thrombosis (DVT), pneumonia, and muscle deconditioning. Unless there are specific contraindications (e.g., unstable vital signs, severe pain, or active bleeding), delaying ambulation unnecessarily can contribute to functional decline and prolonged recovery. The patient’s current assessment (steady gait and intact vision) suggests he is ready for supervised mobility. **D: Consult a physical therapist before allowing the patient to ambulate** While physical therapists play a crucial role in rehabilitation, immediate consultation is not necessary in this scenario. The patient is not exhibiting high-risk mobility limitations (e.g., severe weakness or balance deficits) that would require specialized assessment. Nurses are trained to assist with initial postoperative ambulation, and delaying mobility to wait for PT could hinder the patient's recovery progress. PT referral may be appropriate later if the patient demonstrates persistent difficulties, but routine first-time ambulation after surgery is within nursing scope. In summary, accompanying the patient ensures safety without unnecessarily restricting mobility or delaying recovery, while the other options either risk harm (A), inhibit progress (B), or introduce unnecessary delays (D) in care. The nurse’s role is to balance encouragement of activity with vigilant supervision to optimize recovery.

Correct Answer: D

Rationale: When a patient is emotionally affected, it is essential to acknowledge their feelings while providing reassurance and information. Option D demonstrates empathy by acknowledging the difficulty Mrs. Lim is facing and offers hope by reassuring her that her hair will grow back after chemotherapy, which can provide comfort and support during a challenging time.

Correct Answer: B

Rationale: Vitamin C requirements are increased during infancy, childhood, and pregnancy due to growth and development. However, during young adulthood, the body generally requires a consistent amount of Vitamin C as it is not undergoing rapid growth or physiological changes that necessitate an increase in Vitamin C intake.

Correct Answer: D

Rationale: In patients with COPD, the respiratory drive is often stimulated by low oxygen levels. Administering too much oxygen can inhibit this hypoxic drive, leading to respiratory depression and potential respiratory failure. Therefore, it is crucial to carefully regulate the oxygen therapy to prevent the inhibition of the respiratory hypoxic stimulus in COPD patients.

Correct Answer: C

Rationale: Muscle weakness is a hallmark symptom of hypokalemia. Hypokalemia refers to low levels of potassium in the blood, which can affect muscle function. The decreased potassium levels can lead to muscle weakness, cramping, and even paralysis. These symptoms can impact various muscle groups in the body, making muscle weakness the most significant symptom to monitor and address in patients with hypokalemia.