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The nurse is reinforcing teaching on oral care and symptom management to a client with head and neck cancer who has developed mouth sores related to external radiation therapy. Which of the following instructions should the nurse include? Select all that apply.
- A. Apply a water-soluble lubricating agent to moisturize mouth tissue
- B. Avoid hot liquids and foods that are spicy or acidic
- C. Brush your teeth with a soft-bristle toothbrush
- D. Cleanse the mouth with saline after meals and at bedtime
- E. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor
Correct Answer: A,B,C,D
Rationale: Water-soluble lubricant , avoiding irritants , soft brushing , and saline rinses promote comfort. Alcohol-based mouthwash irritates sores.
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A nurse is caring for a client with blindness due to diabetic retinopathy. Which interventions should the nurse implement for this client? Select all that apply.
- A. Ask a family member about the client's preferences for room arrangement
- B. Offer the client an elbow to hold, and walk a half-step ahead for guidance
- C. Say 'goodbye' when leaving the room to help orient the client
- D. Speak slowly and slightly louder so the client can understand
- E. Use a clock-face pattern to explain food arrangement on the client's meal tray
Correct Answer: B,C,E
Rationale: Guiding with an elbow , saying goodbye , and clock-face food arrangement promote safety and orientation. Family input is secondary, and louder/slower speech is unnecessary unless hearing-impaired.
The nurse is caring for a 5-year-old client who is dehydrated and malnourished, and suspects that the client may be neglected. Which information most strongly supports the nurse's suspicion of child neglect?
- A. The parent cannot stay at the hospital due to potential job loss from absence
- B. The parent is in the process of a divorce and will soon be a single parent
- C. The parent is witnessed stealing food and drinks from the cafeteria
- D. The parent leaves the client's younger sibling to care for the client's newborn sibling
Correct Answer: D
Rationale: Leaving a young child to care for a newborn indicates inadequate supervision, supporting neglect. Job constraints , divorce , and stealing food suggest stress but not direct neglect.
The nurse is providing home care to a man who had a transsphenoidal hypophysectomy the day before yesterday. Which behavior by the client indicates a need for more teaching?
- A. He bends over to tie his shoes.
- B. He tells the nurse he takes a lot of pills every day.
- C. He ambulates daily.
- D. He tells the nurse he has ordered a medical identification bracelet.
Correct Answer: A
Rationale: Bending over increases intracranial pressure, risking cerebrospinal fluid leak post-hypophysectomy, indicating a need for further teaching on activity restrictions.
The nurse is caring for a client with community acquired pneumonia. When collecting client data, the nurse should anticipate which findings? Select all that apply.
- A. Crackles
- B. High-pitched wheezing
- C. Hyperresonance
- D. Pleural chest pain
- E. Productive cough
Correct Answer: A,D,E
Rationale: Crackles , pleural pain , and productive cough are typical in pneumonia. Wheezing suggests asthma, and hyperresonance indicates air trapping.
The health care provider prescribes phenazopyridine hydrochloride for a client with a urinary tract infection. What would the office nurse remind the client to expect while taking this medication?
- A. Constipation
- B. Difficulty sleeping
- C. Discoloration of urine
- D. Dry mouth
Correct Answer: C
Rationale: Phenazopyridine causes orange-red urine discoloration, a benign effect. Constipation , insomnia , and dry mouth are not typical.