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 ["A","C","E"]

Explanation

A. Overexposure to ultraviolet light is a major risk factor for skin cancer, especially from prolonged sun exposure or tanning beds. UV radiation damages skin cells and increases the risk of skin cancer.
B. Skin cancer risk increases with age, particularly for basal cell carcinoma and squamous cell carcinoma. Melanoma is more common in younger individuals, but overall, age is a risk factor for many types of skin cancer.
C. Scars, burns, or other skin injuries can increase the risk of developing skin cancer, particularly squamous cell carcinoma, in the affected area.
D. Darker skin has more melanin, which provides some protection against UV radiation. While dark-skinned individuals are less likely to develop skin cancer, they are not immune, and it is still possible, especially for melanoma.
E. A family history of skin cancer increases the risk. Certain genetic mutations, such as those in the CDKN2A gene, can predispose individuals to skin cancer.

A. Lactated Ringers intravenous fluid B. Metoprolol C. Epinephrine D. Dopamine E. Furosemide

Correct Answer is A

Explanation

A. Neurogenic shock is characterized by hypotension due to loss of sympathetic tone, leading to vasodilation. Intravenous fluids like Lactated Ringers are commonly prescribed to increase blood volume and support blood pressure.
B. Metoprolol is a beta-blocker, which reduces heart rate and blood pressure. It would not be used in neurogenic shock, where the goal is to improve blood pressure and cardiac output.
C. Epinephrine is a vasopressor and can be used to help increase blood pressure and heart rate in shock states, including neurogenic shock. It helps in vasoconstriction and improving perfusion.
D. Dopamine is another vasopressor and inotropic agent that can be used to improve blood pressure and cardiac output in neurogenic shock. It works by stimulating the heart and constricting blood vessels.
E. Furosemide is a diuretic, and would not typically be used in neurogenic shock. In fact, it may worsen hypoperfusion by decreasing circulating blood volume. Diuretics are usually used for conditions like heart failure or fluid overload, not shock management

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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

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