A nurse is caring for a school-age child who has full-thickness burns to 30% of the total body surface area (TBSA). The nurse is initiating the client's plan of care. Complete the following sentence by using the list of options.
The client is at highest risk for developing

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, evidenced by the client's

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.

Choice A reason: Herpes simplex is a viral infection that causes painful blisters or ulcers in the mouth or on the lips. It does not cause a white, milky plaque that does not come off with rubbing.

Choice B reason: Dermatitis is a skin inflammation that causes redness, itching, and scaling. It does not affect the mouth or cause a white, milky plaque that does not come off with rubbing.

Choice C reason: Squamous cell carcinoma is a type of skin cancer that develops from the squamous cells that line the mouth and other parts of the body. It causes a hard, irregular, or ulcerated growth that may bleed or become infected. It does not cause a white, milky plaque that does not come off with rubbing.

Choice D reason: Candidiasis, also known as oral thrush, is a fungal infection that causes a white, milky plaque that coats the tongue, cheeks, and roof of the mouth. It can be scraped off, but may leave a red, sore, or bleeding surface. It is more common in people who have a weakened immune system, such as those who take antibiotics, immunosuppressants, or corticosteroids. It can also be triggered by smoking, dry mouth, or poor oral hygiene.

Choice A reason: Administering alprazolam 0.5 mg PO is not the first action that the nurse should take. Alprazolam is a benzodiazepine that can be used to treat anxiety or insomnia, but it is not a priority intervention for a mother who has experienced a stillbirth. The nurse should assess the mother's emotional and physical needs before giving any medication.

Choice B reason: Contacting the health care facility's clergy is not the first action that the nurse should take. The nurse should respect the mother's spiritual and cultural beliefs and preferences, but not assume that she wants or needs the clergy's presence. The nurse should ask the mother if she would like to have any spiritual support or counseling.

Choice C reason: Offering the mother private time with the newborn is the first action that the nurse should take. This is a sensitive and compassionate way to acknowledge the mother's loss and grief, and to facilitate bonding and closure. The nurse should provide the mother with a quiet and comfortable environment, and allow her to hold, touch, and talk to the newborn as long as she wishes.

Choice D reason: Assisting the client with transferring to the gynecology unit is not the first action that the nurse should take. The nurse should not rush the mother to leave the labor and delivery unit, as this may increase her sense of isolation and abandonment. The nurse should allow the mother to stay in the same room until she is ready to move, and provide her with emotional and physical support during the transition.