A nurse is caring for a client who has AIDS. The client states, “My mouth is sore when I eat.” Which of the following instructions should the nurse provide?
Add salt to season foods.
Rinse your mouth with an alcohol-based mouthwash.
Eat foods served at hot temperatures.
Use ice chips to numb your mouth.
The Correct Answer is D
Choice A reason: Adding salt to season foods can irritate oral sores in AIDS patients, often caused by candidiasis or herpes. Salt exacerbates pain and delays healing, making this instruction harmful and inappropriate for managing oral discomfort in this population.
Choice B reason: Rinsing with alcohol-based mouthwash worsens oral soreness, as alcohol irritates mucosal lesions common in AIDS. Non-alcohol, antiseptic, or saline rinses are preferred to promote comfort and healing, making this instruction incorrect and potentially painful.
Choice C reason: Eating hot foods can aggravate oral sores, increasing pain and delaying healing in AIDS patients with mucosal damage. Lukewarm or cool foods are better tolerated, making this instruction inappropriate and counterproductive for managing the client’s symptoms.
Choice D reason: Using ice chips numbs the mouth, reducing pain from oral sores during eating for AIDS patients. This non-invasive, soothing intervention is safe and effective, aligning with comfort-focused care for mucosal lesions, making it the correct instruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Offering the breast at hunger cues, like rooting, supports demand feeding, regulating milk supply via prolactin. This ensures adequate nutrition and bonding, critical for infant growth and lactation success, aligning with evidence-based breastfeeding practices for optimal maternal-infant outcomes.
Choice B reason: Limiting feeding to 10 minutes per breast restricts hindmilk intake, rich in fat, reducing nutrition and milk supply. Fixed timing disrupts prolactin-driven lactation, risking inadequate weight gain, contrary to breastfeeding guidelines recommending unrestricted feeding based on infant cues.
Choice C reason: Starting each feeding with the same breast risks unbalanced milk production and engorgement. Alternating breasts ensures even stimulation and emptying, maintaining supply and preventing complications, making this incorrect for supporting effective breastfeeding practices in new parents.
Choice D reason: Feeding every 6 hours is too infrequent for newborns, needing feeds every 2-3 hours to meet nutritional demands and stimulate milk production. Fixed schedules ignore hunger cues, risking dehydration or poor growth, contradicting evidence-based breastfeeding recommendations for infants.
Correct Answer is D
Explanation
Choice A reason: Avoiding reading for 3 months is not a standard instruction post-retinal detachment surgery. Reading may be restricted temporarily (e.g., 1-2 weeks) if specific positioning is required, but 3 months is excessive. Patients are typically advised to avoid straining, not reading, making this instruction incorrect.
Choice B reason: Bending at the waist increases intraocular pressure, which can disrupt retinal repair and lead to re-detachment. Patients should bend at the knees to avoid straining the eye. This instruction is harmful and contraindicated, as it risks complications in the healing retina.
Choice C reason: Lifting objects up to 50 pounds is dangerous post-retinal surgery, as heavy lifting increases intraocular pressure, risking re-detachment. Guidelines typically restrict lifting to 10-20 pounds during recovery (4-6 weeks). This instruction is incorrect, as it poses a significant risk to surgical outcomes.
Choice D reason: Taking a stool softener daily prevents straining during bowel movements, which can increase intraocular pressure and disrupt retinal healing. Constipation is a concern post-surgery due to immobility or pain medications, and stool softeners ensure safe bowel movements, making this the correct instruction.
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