A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy.
Which of the following actions should the nurse include in the plan of care?

Moisten the mucosa with lemon glycerin swabs.

Cleanse the gums with saline soaked gauze.

Administer oral viscous lidocaine.

Schedule routine oral care every 8 hr.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Moisten the mucosa with lemon glycerin swabs is not recommended because lemon glycerin swabs can be acidic and may irritate the oral ulcers further. It's important to avoid irritating substances in the oral cavity to promote healing.

Choice B rationale:

Cleaning the gums with saline-soaked gauze is a gentle and non-irritating method to maintain oral hygiene for a toddler with oral ulcers. Saline solution helps keep the oral cavity clean and reduces the risk of infection without causing further irritation.

Choice C rationale:

Administering oral viscous lidocaine is not recommended for routine use in managing oral ulcers in children. Lidocaine can be absorbed systemically and lead to toxicity, especially in young children. It should only be used under the guidance of a healthcare provider and in specific circumstances where the benefits outweigh the risks.

Choice D rationale:

Scheduling routine oral care every 8 hours is important, but the method of oral care is equally crucial. Using gentle methods like saline-soaked gauze to clean the gums ensures proper hygiene without causing discomfort to the child.

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Correct Answer is C

Explanation

Choice A rationale:

Showing teeth while smiling assesses the facial nerve (cranial nerve VII), not the accessory nerve (cranial nerve XI) The facial nerve controls facial expressions, including smiling.

Choice B rationale:

Following a light in the six cardinal positions assesses extraocular eye movements, which are controlled by the oculomotor nerve (cranial nerve III), trochlear nerve (cranial nerve IV), and abducens nerve (cranial nerve VI) This action does not assess the accessory nerve.

Choice C rationale:

Shrugging the shoulders against mild pressure assesses the function of the accessory nerve (cranial nerve XI) The accessory nerve controls the sternocleidomastoid and trapezius muscles, which are responsible for head rotation and shoulder shrugging. Assessing the strength of these muscles helps evaluate the integrity of the accessory nerve.

Choice D rationale:

Moving the tongue in all directions assesses the hypoglossal nerve (cranial nerve XII), which controls tongue movements. This action does not assess the accessory nerve.

A. Use half-strength formula when feeding the infant. B. Give the infant fruit juice between feedings. C. Keep the infant in a visually stimulating environment. D. Assign consistent nursing staff to care for the infant.

Correct Answer is D

Explanation

Choice A rationale:

Using half-strength formula might not provide enough nutrition for the infant, especially if they have failure to thrive. It's essential to provide adequate nutrition to support growth and development.

Choice B rationale:

Giving fruit juice between feedings can fill the baby's stomach with low-nutrient beverages, decreasing the intake of essential nutrients needed for growth.

Choice C rationale:

Keeping the infant in a visually stimulating environment is important for cognitive and sensory development. However, this alone will not address the underlying issue of failure to thrive, which often requires medical and nutritional interventions.

Choice D rationale:

Assigning consistent nursing staff to care for the infant promotes a stable and trusting environment for the infant. Consistency in care can enhance the infant's sense of security and facilitate bonding. Additionally, it ensures that the infant's progress or any changes in condition are closely monitored by familiar caregivers, leading to prompt interventions if needed.

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A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy.Which of the following actions should the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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A nurse is planning care for a toddler who has developed oral ulcers in response to chemotherapy.
Which of the following actions should the nurse include in the plan of care?