A nurse is reinforcing teaching with a client who has stomatitis. Which of the following instructions should the nurse include in the teaching?
CONTINUE Eat foods high in vitamin B12-
Consume soft, bland foods.
Use lemon glycerin swabs.
Rinse the mouth with an alcohol-based mouthwash.
The Correct Answer is B
Choice A Reason:
Continuing to eat foods high in vitamin B12 is generally a good dietary choice, but it should be done in a way that minimizes irritation to the inflamed oral tissues. The client should choose foods that are soft and gentle on the mouth.
Choice B Reason:
Consume soft, bland foods is correct. When providing instructions to a client with stomatitis (inflammation of the mouth), it's important to recommend a diet that is gentle on the irritated oral tissues. Consuming soft, bland foods can help minimize further irritation and discomfort. Examples of suitable foods may include mashed potatoes, yogurt, oatmeal, applesauce, and other similar items that are easy to chew and swallow.
Choice C Reason:
Using lemon glycerin swabs is not recommended for clients with stomatitis. Lemon can be acidic and may further irritate the mouth. Glycerin swabs alone may be used for oral care, but the lemon component should be avoided.
Choice D Reason:
Rinsing the mouth with an alcohol-based mouthwash is not advisable for clients with stomatitis. Alcohol-based mouthwashes can be harsh and may exacerbate the irritation and pain associated with stomatitis. Clients should be encouraged to use non-alcoholic, mild oral rinses or saline rinses as recommended by their healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The normal range for potassium levels is generally between 3.5 to 5.0 mEq/L. A potassium level of 3.5 mEq/L falls within the lower end of the normal range, suggesting that the client's potassium levels are relatively stable. This finding alone does not indicate the overall effectiveness of the behavioral plan.
The normal range for sodium levels is typically between 135 to 145 mEq/L. A sodium level of 130 mEq/L falls below the normal range and indicates hyponatremia (low sodium levels). Hyponatremia can be a cause for concern, and it suggests that the behavioral management plan may need further attention or adjustments.
The normal range for hemoglobin (Hgb) levels varies depending on factors such as age and gender. However, in general, a Hgb level of 10 g/dL falls below the normal range and indicates anemia. Anemia is a common complication in individuals with anorexia nervosa and can result from inadequate nutrient intake. This finding suggests that the behavioral plan may need further evaluation and adjustment to address the client's nutritional needs.
Body Mass Index (BMI) is a measure that relates weight and height. A BMI of 14.5 indicates severe underweight and is well below the normal range. This finding suggests that the client's nutritional status is still significantly compromised, and the behavioral management plan may require further attention to support weight restoration and overall recovery.
Correct Answer is A
Explanation
Choice A Reason:
Raises all four side-rails on the client's bed .The nurse should intervene when the assistive personnel (AP) raises all four side-rails on the client's bed. Using all four side-rails on the bed is considered a restraint, and its use should be avoided unless there is a specific clinical indication and an order from the healthcare provider. Restraints should only be used when less restrictive alternatives have been attempted and are not successful in preventing the client from falling.
Choice B Reason:
Assisting the client to the bathroom every 2 hours is a proactive measure to help the client maintain their continence and reduce the risk of falls associated with trying to get to the bathroom independently.
Choice C Reason:
Clearing furniture from the path leading to the bathroom helps create a safe and unobstructed environment for the client to navigate.
Choice D Reason:
Locking the wheels on the client's bed is an appropriate safety measure to prevent the bed from moving while the client is getting in or out.
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