A nurse is caring for a client who has AIDS. The client states, "My mouth is sore when I eat." Which of the following instructions should the nurse provide?
"Rinse your mouth with an alcohol-based mouthwash."
"Eat foods served at hot temperatures."
"Use ice chips to numb your mouth."
"Add salt to season foods.”
The Correct Answer is C
Rationale:
A. "Rinse your mouth with an alcohol-based mouthwash.": Alcohol-based mouthwashes can further irritate the mucous membranes, worsen oral discomfort, and dry the oral tissues, especially in clients with mucositis or candidiasis common in AIDS.
B. "Eat foods served at hot temperatures.": Hot foods can aggravate oral sores and cause more pain or tissue damage. Cool or room-temperature foods are typically better tolerated when the mouth is sore.
C. "Use ice chips to numb your mouth.": Ice chips can provide temporary relief by numbing oral tissues, reducing inflammation, and making eating more comfortable. This is a helpful, non-pharmacologic intervention for oral pain.
D. "Add salt to season foods.": Salt can irritate open or inflamed oral tissues and worsen the discomfort. Bland, soft foods without strong seasonings are usually better tolerated in cases of mouth soreness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Place the client upright on a donut-shaped cushion: Donut-shaped cushions are not recommended because they create uneven pressure distribution, which can worsen ischemia around pressure points rather than relieve it, potentially delaying healing.
B. Teach the client to shift his weight every 15 min while sitting: Frequent weight shifting relieves pressure on the ischial area and promotes circulation, helping to prevent progression of a stage 1 pressure injury. This intervention supports client independence and tissue integrity.
C. Assess pressure points every 24 hr: Pressure points should be assessed more frequently than once daily, especially in high-risk clients. Routine skin assessments at least once per shift are critical for early detection of pressure injury progression.
D. Turn and reposition the client every 3 hr while in bed: The standard recommendation is to reposition immobile clients at least every 2 hours in bed to redistribute pressure and reduce the risk of further skin breakdown. Extending intervals increases risk of injury.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
- Evaluating the fetal heart rate tracing: The client’s report of decreased fetal movement and severe hypertension raises concern for fetal compromise. Immediate fetal assessment ensures the fetus is tolerating the intrauterine environment, especially before administering medications like magnesium sulfate.
- Administering magnesium sulfate IV: This is prescribed to prevent eclampsia, given the client’s severely elevated BP, hyperreflexia, and proteinuria. After confirming fetal status, seizure prophylaxis should be initiated without delay.
Rationale for Incorrect Choices:
- Administering acetaminophen PO: Although ordered for headache, the symptom is a manifestation of severe preeclampsia. Treating it symptomatically without addressing its cause could delay necessary critical interventions.
- Obtaining a 24-hour urine collection: Useful for confirming the extent of proteinuria, but not immediately necessary for clinical decision-making given existing positive findings.
- Inserting an indwelling urinary catheter: This supports fluid monitoring during magnesium therapy, but fetal assessment and seizure prevention take precedence.
- Administering betamethasone IM: Important for fetal lung development in preterm pregnancies, but it is not the immediate priority when there is a high risk for seizure or fetal distress.
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