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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The subdivision of pancreatic tumors into endocrine versus exocrine reflects their cell of origin (islet cells versus ductal cells) rather than conveying information about how the cancer behaves in situ or its propensity for local invasion and metastasis
B. Unlike some other cancers (e.g., colorectal cancer), pancreatic cancer does not typically develop from polyps. Most cases of pancreatic cancer develop from the pancreatic ductal cells (the cells lining the ducts of the pancreas), and the disease is typically aggressive and diagnosed at a later stage.
C. Because the pancreas lies deep in the retroperitoneum directly adjacent to major vessels like the superior mesenteric artery and portal vein, tumors often extend into these structures early, contributing to the high rate of advanced disease at diagnosis
D. Pancreatic cancer is not distinguished based on layers. Instead, it is generally categorized based on the type of cells it affects (e.g., ductal cells in exocrine pancreatic cancer). The staging of pancreatic cancer is based on factors like tumor size, lymph node involvement, and metastasis, rather than the layers of the pancreas.
Correct Answer is ["480"]
Explanation
Convert time to hours:
25 minutes ÷ 60 = 0.4167 hours
Step 2:
Use the formula:
Rate (mL/hr) = Volume (mL) ÷ Time (hr)
Rate = 200 mL ÷ 0.4167 hr ≈ 480 mL/hr
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