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A nurse is performing health education with a patient who has a history of frequent, serious dental caries. When planning educational interventions, the nurse should identify a risk for what nursing diagnosis?
- A. Ineffective Tissue Perfusion
- B. Impaired Skin Integrity
- C. Aspiration
- D. Imbalanced Nutrition: Less Than Body Requirements
Correct Answer: D
Rationale: Because digestion normally begins in the mouth, adequate nutrition is related to good dental health and the general condition of the mouth. Any discomfort or adverse condition in the oral cavity can affect a persons nutritional status. Dental caries do not typically affect the patients tissue perfusion or skin integrity. Aspiration is not a likely consequence of dental caries.
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The school nurse is planning a health fair for a group of fifth graders and dental health is one topic that the nurse plans to address. What would be most likely to increase the risk of tooth decay?
- A. Organic fruit juice
- B. Roasted nuts
- C. Red meat that is high in fat
- D. Cheddar cheese
Correct Answer: A
Rationale: Dental caries may be prevented by decreasing the amount of sugar and starch in the diet. Patients who snack should be encouraged to choose less cariogenic alternatives, such as fruits, vegetables, nuts, cheeses, or plain yogurt. Fruit juice is high in sugar, regardless of whether it is organic.
A nurse is caring for a patient who is postoperative day 1 following neck dissection surgery. The nurse is performing an assessment of the patient and notes the presence of high-pitched adventitious sounds over the patients trachea on auscultation. The patients oxygen saturation is 90% by pulse oximetry with a respiratory rate of 31 breaths per minute. What is the nurses most appropriate action?
- A. Encourage the patient to perform deep breathing and coughing exercises hourly.
- B. Reposition the patient into a prone or semi-Fowlers position and apply supplementary oxygen by nasal cannula.
- C. Activate the emergency response system.
- D. Report this finding promptly to the physician and remain with the patient.
Correct Answer: D
Rationale: In the immediate postoperative period, the nurse assesses for stridor (coarse, high-pitched sound on inspiration) by listening frequently over the trachea with a stethoscope. This finding must be reported immediately because it indicates obstruction of the airway. The patients current status does not warrant activation of the emergency response system, and encouraging deep breathing and repositioning the patient are inadequate responses.
An emergency department nurse is admitting a 3-year-old brought in after swallowing a piece from a wooden puzzle. The nurse should anticipate the administration of what medication in order to relax the esophagus to facilitate removal of the foreign body?
- A. Haloperidol
- B. Prostigmine
- C. Epinephrine
- D. Glucagon
Correct Answer: D
Rationale: Glucagon is administered prior to removal of a foreign body because it relaxes the smooth muscle of the esophagus, facilitating insertion of the endoscope. Haloperidol is an antipsychotic drug and is not indicated. Prostigmine is prescribed for patients with myasthenia gravis. It increases muscular contraction, an effect opposite that which is desired to facilitate removal of the foreign body. Epinephrine is indicated in asthma attack and bronchospasm.
An elderly patient comes into the emergency department complaining of an earache. The patient has an oral temperature of 100.2 F and otoscopic assessment of the ear reveals a pearly gray tympanic membrane with no evidence of discharge or inflammation. Which action should the triage nurse take next?
- A. Palpate the patients parotid glands to detect swelling and tenderness.
- B. Assess the temporomandibular joint for evidence of a malocclusion.
- C. Test the integrity of cranial nerve XII by asking the patient to protrude the tongue.
- D. Inspect the patients gums for bleeding and hyperpigmentation.
Correct Answer: A
Rationale: Older adults and debilitated patients of any age who are dehydrated or taking medications that reduce saliva production are at risk for parotitis. Symptoms include fever and tenderness, as well as swelling of the parotid glands. Pain radiates to the ear. Pain associated with malocclusion of the temporomandibular joint may also radiate to the ears; however, a temperature elevation would not be associated with malocclusion. The 12th cranial nerve is not associated with the auditory system. Bleeding and hyperpigmented gums may be caused by pyorrhea or gingivitis. These conditions do not cause earache; fever would not be present unless the teeth were abscessed.
A nurse is providing oral care to a patient who is comatose. What action best addresses the patients risk of tooth decay and plaque accumulation?
- A. Irrigating the mouth using a syringe filled with a bacteriocidal mouthwash
- B. Applying a water-soluble gel to the teeth and gums
- C. Wiping the teeth and gums clean with a gauze pad
- D. Brushing the patients teeth with a toothbrush and small amount of toothpaste
Correct Answer: D
Rationale: Application of mechanical friction is the most effective way to cleanse the patients mouth. If the patient is unable to brush teeth, the nurse may brush them, taking precautions to prevent aspiration; or as a substitute, the nurse can achieve mechanical friction by wiping the teeth with a gauze pad. Bacteriocidal mouthwash does reduce plaque-causing bacteria; however, it is not as effective as application of mechanical friction. Water-soluble gel may be applied to lubricate dry lips, but it is not part of oral care.