Nokea
A client has a large oral tumor. What assessment by the nurse takes priority?
- A. Airway
- B. Breathing
- C. Circulation
- D. Infection
Correct Answer: A
Rationale: Airway always takes priority. Airway must be assessed first and any problems resolved if present.
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A client had an oral tumor removed this morning and now has a tracheostomy. What action by the nurse is best?
- A. Delegate oral care every 4 hours
- B. Monitor and record the client's intake
- C. Place the client in a semi- or high-Fowler's position
- D. Clean the tracheostomy site daily
Correct Answer: C
Rationale: To promote airway clearance, this client should be placed in a semi- or high-Fowler's position. Oral care can be delegated, but that is not the priority. Intake and output should also be recorded but again is not the priority. The tracheostomy site may or may not need to be cleaned daily, and this is not the priority action.
A client is prescribed cotusimma (Ebitus) for oral cancer and asks the nurse how it works. What response by the nurse is best?
- A. Blocks the epidermal growth factor
- B. Cuts off the tumor's blood supply
- C. Prevents tumor extension
- D. Targets rapidly dividing cells
Correct Answer: A
Rationale: Cetusimma (Ebitus) targets and blocks the epidermal growth factor, which contributes to the growth of oral cancers. The other explanations are not correct.
A nurse has conducted a community screening event for oral cancer. What client is the highest priority for referral to a dentist?
- A. Client who has poor oral hygiene practices
- B. Client who smokes and drinks daily
- C. Client who uses for an upcoming vacation
- D. Client who occasionally uses illicit drugs
Correct Answer: B
Rationale: Smoking and alcohol exposure create a high risk for this client. Poor oral hygiene is not related to the etiology of cancer but may cause a tumor to go unnoticed. Tanning is a risk factor, but short-term exposure does not have the same risk as daily exposure to tobacco and alcohol. Illicit drugs are not related to oral cancers.
A nurse assesses a clients oral cavity and observes the condition depicted in the photo below. What action by the nurse is best?
- A. Document the findings and continue monitoring
- B. Refer the client to a dentist immediately
- C. Apply a topical anesthetic to the lesion
- D. Educate the client on oral hygiene practices
Correct Answer: B
Rationale: Given the context of oral cavity assessment and the presence of a condition depicted in a photo, the best action is to refer the client to a dentist immediately for further evaluation, as the condition could indicate a serious issue such as oral cancer. Documenting and monitoring is important but not sufficient as the primary action. Applying a topical anesthetic is inappropriate without a diagnosis, and education on oral hygiene is secondary to professional evaluation.
A female client hospitalized for an unrelated problem has a large partly-white lesion on her lip, to which she is the nurse or health care provider. What action by the nurse is best?
- A. Ask the client why her appearance is so important
- B. Ignore the lesion since the client and not discuss it
- C. Inform the client that early-stage cancer is curable
- D. Know with the client to establish a trusting relationship
Correct Answer: D
Rationale: Clients with oral cancers often have body image difficulties due to the location of the tumor or the results of surgical treatment. This client appears to be using denial to cope with this problem. The nurse should work to establish a helping-trusting relationship in hopes that the client will be amenable to future discussions about the lesion. Asking why questions often puts people on the defensive and should be avoided. Ignoring the lesion is not being an advocate for the client. Education is important, but right now the client is in denial, so this information will not seem relevant to her.