Which action will the nurse take when assessing a patient with possible oral cancer?
Palpate over the maxillary sinuses.
Ask about a productive cough.
Observe for purulent nasal drainage.
Check the mouth for leukoplakia.
The Correct Answer is D
Choice A rationale
Palpating over the maxillary sinuses is not typically associated with oral cancer assessment. This action is more relevant to sinus issues and does not provide information about oral cancer.
Choice B rationale
Asking about a productive cough can be relevant in assessing respiratory conditions but is not a direct method for evaluating oral cancer. Oral cancer symptoms are more localized to the mouth area.
Choice C rationale
Observing for purulent nasal drainage is not a standard action in assessing for oral cancer. Nasal drainage would be more indicative of sinus or respiratory issues, not oral pathology.
Choice D rationale
Checking the mouth for leukoplakia is a key action when assessing for oral cancer. Leukoplakia presents as thickened, white patches inside the mouth and can be precancerous, making it a critical observation in potential oral cancer cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
Hemoglobin released from hemolyzed red blood cells (RBCs) can cause intrarenal acute kidney injury by obstructing the renal tubules and damaging the nephrons.
Choice B rationale
Benign prostatic hyperplasia is a cause of postrenal, not intrarenal, acute kidney injury as it can obstruct the flow of urine out of the bladder.
Choice C rationale
Prostate cancer, similar to benign prostatic hyperplasia, typically leads to postrenal acute kidney injury due to urinary obstruction.
Choice D rationale
Myoglobin released from necrotic muscle cells, as seen in conditions like rhabdomyolysis, can cause intrarenal acute kidney injury by precipitating in the renal tubules.
Choice E rationale
Nephrotoxins, such as certain medications, chemicals, or toxins, can directly damage the kidney tissue, leading to intrarenal acute kidney injury.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale
Anxiety, while a valid concern, is not directly a risk associated with the physical complications of an ileal conduit. However, it can be an emotional response to the surgery and the changes it brings.
Choice B rationale
Impaired skin integrity is a significant risk for clients with an ileal conduit due to the potential for irritation from the stoma appliance and the risk of skin breakdown around the stoma site.
Choice C rationale
Infection is a risk due to the potential for bacteria to enter through the stoma or for urinary tract infections to develop, given the changes in the urinary system's structure and function.
Choice D rationale
Fluid volume deficit is a risk for clients with an ileal conduit because of the potential for increased fluid loss through the stoma, necessitating careful monitoring and management of fluid intake and output.
Choice E rationale
Disturbed body image is a risk due to the physical changes and the presence of a stoma, which can affect the client's perception of their body and self-image.
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