Nokea
A patient has received treatment for oral cancer. The combination of medications and radiotherapy has resulted in leukopenia. Which of the following is an appropriate response to this change in health status?
- A. Ensure that none of the patients visitors has an infection.
- B. Arrange for a diet that is high in protein and low in fat.
- C. Administer colony stimulating factors (CSFs) as ordered.
- D. Prepare to administer chemotherapeutics as ordered.
Correct Answer: A
Rationale: Leukopenia reduces defense mechanisms, increasing the risk of infections. Visitors who might transmit microorganisms are prohibited if the patients immunologic system is depressed. Changes in diet, CSFs, and the use of chemotherapy do not resolve leukopenia.
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The nurses comprehensive assessment of a patient includes inspection for signs of oral cancer. What assessment finding is most characteristic of oral cancer in its early stages?
- A. Dull pain radiating to the ears and teeth
- B. Presence of a painless sore with raised edges
- C. Areas of tenderness that make chewing difficult
- D. Diffuse inflammation of the buccal mucosa
Correct Answer: B
Rationale: Malignant lesions of the oral cavity are most often painless lumps or sores with raised borders. Because they do not bother the patient, delay in seeking treatment occurs frequently, and negatively affects prognosis. Dull pain radiating to the ears and teeth is characteristic of malocclusion. Inflammation of the buccal mucosa causes discomfort and often occurs as a side effect of chemotherapy. Tenderness resulting in pain on chewing may be associated with gingivitis, abscess, irritation from dentures, and other causes. Pain related to oral cancer is a late symptom.
A nurse is caring for a patient who is acutely ill and has included vigilant oral care in the patients plan of care. Why are patients who are ill at increased risk for developing dental caries?
- A. Hormonal changes brought on by the stress response cause an acidic oral environment
- B. Systemic infections frequently migrate to the teeth
- C. Hydration that is received intravenously lacks fluoride
- D. Inadequate nutrition and decreased saliva production can cause cavities
Correct Answer: D
Rationale: Many ill patients do not eat adequate amounts of food and therefore produce less saliva, which in turn reduces the natural cleaning of the teeth. Stress response is not a factor, infections generally do not attack the enamel of the teeth, and the fluoride level of the patient is not significant in the development of dental caries in the ill patient.
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.
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 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.