You are caring for an 11-year-old girl with Acute Lymphoblastic Leukemia (ALL). She is inpatient receiving chemotherapy and has developed mucositis. Select which nursing interventions you would anticipate for this patient. Select THREE that apply.
Perform meticulous oral care with a hard bristled tooth brush.
Initiate NPO orders to minimize pain.
Administer a mouthwash with numbing and antibacterial agents.
Encourage a soft, bland diet and proper hydration
Monitor for rectal involvement and administer stool softeners.
Correct Answer : C,D,E
Rationale:
A. Perform meticulous oral care with a hard bristled toothbrush: A hard bristled toothbrush can easily damage the delicate and inflamed mucosa in a patient with mucositis, increasing pain, risk of bleeding, and potential entry points for infection. Using a soft-bristled toothbrush is safer.
B. Initiate NPO orders to minimize pain: Avoiding food altogether is generally not beneficial unless swallowing is unsafe, as it can lead to malnutrition and dehydration. Managing pain and modifying the diet is preferred so the patient can continue to receive nutrition and fluids.
C. Administer a mouthwash with numbing and antibacterial agents: These solutions help reduce discomfort during eating and oral care while lowering bacterial load in the mouth, which is important for infection prevention in immunocompromised patients.
D. Encourage a soft, bland diet and proper hydration: Soft, mild foods are less abrasive to oral tissues, and adequate fluid intake supports tissue healing and overall recovery. Eliminating rough, acidic, or spicy foods can help avoid worsening mucosal irritation.
E. Monitor for rectal involvement and administer stool softeners: Mucositis can affect the gastrointestinal tract beyond the mouth, leading to painful or fragile rectal mucosa. Stool softeners reduce the risk of trauma from straining during bowel movements, helping to prevent bleeding and discomfort.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A: Measles (rubeola): Koplik spots are small, bluish-white lesions with a red base that appear on the buccal mucosa, typically near the molars. They are a hallmark sign of measles and usually appear 1–2 days before the characteristic maculopapular rash develops. Their presence strongly supports a measles diagnosis in a symptomatic child.
B: Chicken pox: This viral illness caused by varicella-zoster virus is characterized by a vesicular rash in various stages of healing, beginning on the trunk and spreading outward. Oral lesions may occur but they are vesicular, not the pinpoint bluish-white lesions.
C: Exanthema subitum (roseola): Caused most often by human herpesvirus 6, roseola presents with high fever followed by a sudden pink maculopapular rash after the fever subsides. Koplik spots are not associated with this illness.
D: Rubella: Also known as German measles, rubella presents with a fine pink rash, lymphadenopathy, and mild symptoms. There are no Koplik spots; instead, enanthem is rare and nonspecific if present
Correct Answer is D
Explanation
Rationale:
A. Recommend immediate drug testing to confirm substance use: While drug testing may be part of the assessment process, it is not the first priority. Establishing trust and gathering history from the adolescent is essential before moving to diagnostic measures.
B. Reassure the parent that behavioral changes are a normal part of adolescence: Although moodiness and peer changes can occur in adolescence, the presence of multiple risk factors, withdrawal, irritability, poor academic performance, requires further assessment rather than reassurance.
C. Tell the adolescent that substance use can lead to serious consequences and should be avoided: Providing education about risks is important, but doing this before assessing the situation may shut down communication and make the teen defensive.
D. Ask the adolescent directly about substance use in a private, non-judgmental manner: This allows the nurse to gather accurate information in a confidential environment, promoting trust and honest disclosure which are critical for further planning and intervention.
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