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?
"Rinse your mouth with an alcohol-based mouthwash."
"Eat foods served at hot temperatures."
"Use ice chips to numb your mouth."
"Add salt to season foods.”
The Correct Answer is C
Rationale:
A. "Rinse your mouth with an alcohol-based mouthwash.": Alcohol-based mouthwashes can further irritate the mucous membranes, worsen oral discomfort, and dry the oral tissues, especially in clients with mucositis or candidiasis common in AIDS.
B. "Eat foods served at hot temperatures.": Hot foods can aggravate oral sores and cause more pain or tissue damage. Cool or room-temperature foods are typically better tolerated when the mouth is sore.
C. "Use ice chips to numb your mouth.": Ice chips can provide temporary relief by numbing oral tissues, reducing inflammation, and making eating more comfortable. This is a helpful, non-pharmacologic intervention for oral pain.
D. "Add salt to season foods.": Salt can irritate open or inflamed oral tissues and worsen the discomfort. Bland, soft foods without strong seasonings are usually better tolerated in cases of mouth soreness.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
Rationale:
- Prolonged rupture of membranes: Membranes ruptured for over 24 hours (28 hr), increasing the risk for ascending bacterial infections such as endometritis or chorioamnionitis.
- Prenatal anemia: Anemia reduces immune function and tissue oxygenation, making the client more susceptible to postpartum infections, including uterine and systemic infections.
- Polyhydramnios: Excessive amniotic fluid causes uterine overdistension, which weakens uterine contractility and increases the risk of atony and postpartum hemorrhage.
- High parity: Repeated stretching of the uterus in grand multiparity reduces muscle tone, making the uterus less responsive to postpartum contraction and more prone to atony.
Correct Answer is ["A","B","E"]
Explanation
Rationale:
A. "Attempt to void every 2 hours.": Scheduled voiding helps reduce the likelihood of bladder overfilling and decreases episodes of leakage, especially in stress incontinence where physical pressure causes urine loss.
B. "Perform Kegel exercises several times daily.": Kegel exercises strengthen the pelvic floor muscles, which support the bladder and urethra. Regular practice improves muscle tone and helps control urine leakage during activities like coughing or sneezing.
C. "Maintain a daily fluid intake of 1,000 to 1,200 mL/day.": Limiting fluids excessively can lead to concentrated urine and bladder irritation, increasing urgency and risk of infection. A moderate, well-balanced intake closer to 1,500–2,000 mL/day is generally recommended.
D. "Take prescribed diuretics no later than 2000.": While relevant for fluid management, it's not a direct or primary instruction specifically for treating or managing stress incontinence itself. Diuretics increase urine production, which could potentially worsen incontinence.
E. "Maintain optimal body weight for height.": Excess weight increases abdominal pressure on the bladder, worsening stress incontinence. Achieving and maintaining a healthy weight can reduce symptoms and support pelvic muscle strength.
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