The nurse is caring for a client with the nursing problem of Imbalanced Nutrition: Less than Body Requirements related to painful oral lesions. Which intervention would the nurse include in the plan of care?

Encourage rinsing mouth twice a day with a sodium bicarbonate solution

Encourage client to perform mouth care before and after every meal

Assess oral pain level once a shift

Offer 3 meals per day with a snack at bedtime

Answer and Explanation

The Correct Answer is B

A. While mouth rinses can be helpful for some oral conditions, sodium bicarbonate solutions may not be appropriate for all types of oral lesions, and there are other more effective mouth care strategies for managing painful lesions.
B. This is a key intervention for managing painful oral lesions. Regular mouth care helps to maintain oral hygiene, reduce the risk of infection, and decrease discomfort while eating. It also promotes healing and prevents further complications.
C. While assessing pain is important, doing it just once a shift may not be sufficient. The nurse should assess pain more frequently, especially before and after meals, as pain from oral lesions can significantly impact a client’s ability to eat.
D. Offering small, frequent meals is typically more effective in improving nutrition for clients with painful oral lesions. The client may be more willing to eat smaller amounts rather than large meals, especially if pain is a significant issue.

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Correct Answer is ["B","D","E"]

Explanation

A. Fever and cardiac dysrhythmias are not specific complications of tissue plasminogen activator (t-PA) therapy. While they can occur after a stroke or as a general response to illness, they are not the primary indicators of complications related to thrombolytic therapy.

B. An elevated blood pressure combined with a headache could indicate a hemorrhagic transformation, which is a serious complication after t-PA administration. Thrombolytic therapy increases the risk of bleeding, and these symptoms may signal intracranial hemorrhage.

C. A positive Babinski's sign (extensor plantar response) is often seen in stroke patients as a neurological finding, but it is not specifically an indication of a complication from t-PA therapy. It is more reflective of the brain injury or stroke itself rather than the medication.

D. Nausea and vomiting can be signs of increased intracranial pressure (ICP), which could result from hemorrhage following t-PA therapy. This is a critical sign that requires immediate evaluation to rule out complications such as bleeding.

E. A decreased level of consciousness is a significant red flag and may indicate cerebral hemorrhage or another serious complication related to the administration of t-PA. Monitoring for changes in neurological status is crucial following thrombolytic therapy.

A. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer?" B. "Even though I am not hurting right now. I don't feel like have the energy to get out of bed. C. The doctor has been so good to me. I know he has tried everything he can. It is just my time. D. The doctor says I only have a few months to live, but know he is exaggerating to get me to take my medication."

Correct Answer is D

Explanation

A. "I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer?" This statement reflects anger rather than denial. In the anger stage of grief, individuals may direct their frustration toward others, including healthcare providers, feeling that they have been wronged or mistreated.

B. "Even though I am not hurting right now, I don't feel like I have the energy to get out of bed." This statement indicates depression rather than denial. Depression in the grieving process often includes feelings of fatigue, sadness, or a lack of motivation, and is characterized by a sense of hopelessness or resignation.

C. "The doctor has been so good to me. I know he has tried everything he can. It is just my time." This statement indicates acceptance, the final stage of the grief process. Acceptance involves coming to terms with the reality of the situation, recognizing that the end is near, and being at peace with it.

D. "The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication." Denial is a defense mechanism in which the person refuses to accept the reality of the situation. In this case, the client is rejecting the doctor's prognosis, believing that the doctor is exaggerating, which is characteristic of the denial phase of grief.

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The nurse is caring for a client with the nursing problem of Imbalanced Nutrition: Less than Body Requirements related to painful oral lesions. Which intervention would the nurse include in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["B","D","E"]

Explanation

A nurse is caring for a client who has been diagnosed with end-stage liver cancer. Which of the following responses is an indication the client is in the denial phase of the grief process?

Correct Answer is D

Explanation

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The nurse is caring for a client with the nursing problem of Imbalanced Nutrition: Less than Body Requirements related to painful oral lesions. Which intervention would the nurse include in the plan of care?

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