A female client is taking a bisphosphonate for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Report the client's jaw pain to the healthcare provider (HCP).

Confirm that this is a common symptom of osteoporosis.

Determine how the client is administering the medication.

Advise the client to gargle with warm salt water twice daily.

Answer and Explanation

The Correct Answer is A

Brief introduction:

Bisphosphonates are a class of medications (such as alendronate or zoledronic acid) used to inhibit osteoclastic bone resorption, thereby increasing bone mineral density and reducing fracture risk in postmenopausal women. However, a rare but severe adverse effect of long-term or high-dose bisphosphonate therapy is Osteonecrosis of the Jaw (ONJ). This condition is characterized by the death of jawbone tissue, typically following invasive dental work or trauma, and often presents as persistent pain, swelling, or exposed bone that fails to heal.

Rationale:

A. Reporting the jaw pain to the healthcare provider is the priority action. Because ONJ is a serious complication that can lead to permanent bone damage or the need for surgery, the HCP must be notified immediately to evaluate the client and potentially suspend the medication. Early detection is critical to preventing the progression of bone necrosis.

B. Jaw pain is not a common symptom of osteoporosis. Osteoporosis is often a "silent" disease until a fracture occurs, and it typically affects the spine, hips, or wrists. Attributing jaw pain to the underlying disease would be a dangerous clinical oversight that ignores a known medication-induced emergency.

C. Determining administration technique (e.g., staying upright for 30 minutes, taking on an empty stomach) is vital for preventing esophageal irritation, but it does not address the acute risk of jaw necrosis. While administration education is a key part of bisphosphonate therapy, it is secondary to the immediate safety risk indicated by jaw pain.

D. Advising the client to gargle with salt water is an inappropriate and ineffective intervention for bone necrosis. Saltwater gargles are used for minor oral irritations or sore throats, but they cannot treat the deep ischemic bone death associated with bisphosphonate-related ONJ. This response delays necessary medical intervention.

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Correct Answer is B

Explanation

Neisseria meningitidis is a highly contagious bacterium that causes meningococcal meningitis, characterized by inflammation of the protective membranes covering the brain and spinal cord. Transmission occurs through respiratory and oropharyngeal secretions, necessitating strict adherence to droplet precautions to prevent healthcare-acquired infections. The sudden onset of severe headache and projectile vomiting often indicates an acute rise in intracranial pressure requiring immediate clinical assessment.

Rationale:

A. It is not necessary for the nurse to assume full care for a client simply because isolation protocols are in place. The nurse can safely delegate tasks to the unlicensed personnel as long as the assistant is properly educated on the required personal protective equipment.

B. The nurse must ensure the assistant wears a surgical mask when within 3 to 6 feet of the client. Droplet precautions are mandatory for Neisseria meningitidis to block the transmission of large-particle droplets expelled during coughing or talking. This action protects the staff member from mucosal exposure to the pathogen.

C. A fitted respirator mask, such as an N95, is specifically required for airborne precautions, which apply to pathogens like Mycobacterium tuberculosis. Neisseria meningitidis particles are heavier and do not remain suspended in the air, making a standard mask and face shield sufficient for bedside care. Incorrectly identifying the isolation category leads to unnecessary resource consumption.

D. While monitoring emesis is important, the immediate priority is ensuring the safety of the staff before they enter the room. Instructing the assistant on clinical observations does not address the breach in protocol regarding infection control. The nurse must prioritize barrier protection to prevent the spread of the meningitis bacteria.

A. Use sterile technique during feedings. B. Speak to the healthcare provider about instituting physical therapy. C. Offer a pacifier for non-nutritive sucking. D. Ensure placement of the gastrostomy tube with an abdominal x-ray.

Correct Answer is C

Explanation

Esophageal atresia involves a congenital failure of the esophagus to form a continuous passage, while a tracheoesophageal fistula creates an abnormal communication between the trachea and esophagus. These defects pose extreme risks for aspiration pneumonia and require surgical correction shortly after birth. Postoperative care focuses on maintaining airway patency, ensuring nutritional intake, and supporting the development of oral motor skills during the transition to enteral feeding.

Rationale:

A. Standard clean technique is typically sufficient for enteral feedings as the gastrointestinal tract is not a sterile environment. Using sterile technique is unnecessary and does not contribute to the infant's developmental milestones or growth. Nursing care should prioritize safety and comfort rather than redundant infection control measures for stable gastrostomy sites.

B. While physical therapy helps with gross motor skills, it is not the most significant factor for growth in an infant with feeding challenges. The primary developmental hurdle for these infants is the potential for oral aversion due to prolonged lack of oral intake. Interventions should target the specific sensory needs of the neonatal period.

C. Offering a pacifier provides non-nutritive sucking, which is vital for infants who cannot feed orally. This action associates the sensation of sucking with the feeling of a full stomach provided by enteral feeds. It prevents the loss of the sucking reflex and facilitates an easier transition to oral feedings later.

D. Although confirming tube placement is a critical safety step, it is performed immediately after surgery rather than as a routine part of developmental care. Daily or frequent abdominal x-rays expose the infant to unnecessary ionizing radiation without providing developmental benefit. Placement is typically verified by gastric pH or measurement markings before each feeding.

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A female client is taking a bisphosphonate for postmenopausal osteoporosis. The client tells the nurse that she is experiencing jaw pain. How should the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with Neisseria meningitidis calls the nurses station to report a severe headache and vomiting. The unlicensed assistive personnel (UAP) approaches the room to provide an emesis basin and is stopped by the nurse. Which action should the nurse take?

Correct Answer is B

Explanation

An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for enteral feedings after corrective surgery. To promote normal growth and development of the infant, which action should the nurse include in the plan of care?

Correct Answer is C

Explanation

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