A nurse is planning care for a client who reports smoking and occasional mouth sores. Which of the following actions should the nurse prioritize in the care plan?
Refer the client to a speech therapist.
Recommend switching to a vape instead, as it is better for oral health.
Schedule a dental cleaning for the client.
Provide education to the client on the effects of smoking on oral health.
The Correct Answer is D
A. Referring to a speech therapist is not the priority action for a client reporting smoking and mouth sores. Speech therapy focuses on communication or swallowing disorders, not prevention or education regarding oral health risks related to smoking.
B. Recommending switching to vaping is inappropriate. Vaping still exposes the oral cavity and respiratory system to harmful chemicals and does not eliminate risk for oral lesions, cancer, or gum disease. It is not a safe alternative.
C. Scheduling a dental cleaning is beneficial for oral health, but it addresses only one aspect of prevention and does not target the underlying risk behavior of smoking. While important, it is secondary to educating the client about smoking’s effects.
D. Providing education on the effects of smoking on oral health is the priority nursing action. Smoking is a major risk factor for oral cancers, periodontal disease, delayed healing, and recurrent mouth sores. Education empowers the client to understand these risks, promotes behavioral change, and is the first step in a preventive care plan. The nurse can also incorporate smoking cessation resources and monitor for early signs of oral pathology.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tracheal deviation is a classic and life-threatening sign of a tension pneumothorax. In this condition, air accumulates in the pleural space and cannot escape, causing increased intrathoracic pressure. This pressure shifts mediastinal structures, including the trachea, away from the affected side. A tension pneumothorax can rapidly lead to respiratory distress, decreased venous return, shock, and cardiac arrest. This finding requires immediate intervention (such as needle decompression or chest tube placement). According to trauma priorities (Airway, Breathing, Circulation), airway and breathing issues always take precedence.
B. Bruising may indicate blunt trauma and possible internal injury, such as rib fractures or pulmonary contusion. While this requires further evaluation, it is not immediately life-threatening unless accompanied by respiratory compromise. It does not take priority over a potentially fatal airway emergency.
C. Headache and dizziness may indicate a concussion or mild traumatic brain injury. These symptoms require assessment and monitoring but are not immediately life-threatening unless accompanied by altered level of consciousness, unequal pupils, or neurological deficits. They do not supersede airway compromise.
D. Superficial abrasions are minor soft tissue injuries. They require cleaning and monitoring for infection but are not urgent or life-threatening. They are the lowest priority among the options provided.
Correct Answer is C
Explanation
A. A rate of 20 is at the upper limit of normal for adults, which ranges from 12 to 20 breaths per minute. While slightly elevated, it is not classified as tachypnea. Tachypnea specifically refers to a respiratory rate above 20, indicating increased work of breathing or an underlying physiological stress.
B. A rate of 14 is well within the normal adult range and does not represent tachypnea. This rate indicates normal, resting breathing and does not suggest respiratory compromise or increased metabolic demand.
C. A respiratory rate of 26 is above the normal range and represents tachypnea. Tachypnea can occur in response to various conditions, including fever, pain, anxiety, hypoxia, or underlying respiratory or cardiovascular disorders such as pneumonia, chronic obstructive pulmonary disease (COPD) exacerbations, or pulmonary embolism. This increased rate is a compensatory mechanism to meet the body’s oxygen demand or remove carbon dioxide more efficiently. Identifying tachypnea allows the nurse to perform a thorough assessment, including checking oxygen saturation, observing for use of accessory muscles, evaluating breathing pattern, and identifying potential underlying causes. Early recognition of tachypnea is critical to prevent hypoxia or respiratory failure.
D. A rate of 8 indicates bradypnea, which is abnormally slow breathing. Bradypnea may result from respiratory depression due to medications, neurological injury, or metabolic disturbances. It is the opposite of tachypnea and does not match the clinical assessment of rapid breathing.
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