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 C
Explanation
Rationale:
A. "You should avoid vaginal spermicides while breastfeeding.": Vaginal spermicides are generally considered safe during breastfeeding. They do not contain hormones and do not affect milk production, so avoidance is not typically necessary unless the client has specific contraindications.
B. "The lactation amenorrhea method is effective for your first year postpartum.": This method is only effective during the first 6 months postpartum, provided the mother is exclusively breastfeeding and menstruation has not resumed. Beyond that period, the risk of ovulation increases and it becomes unreliable.
C. "Place the transdermal birth control patch on your upper outer arm.": The patch can be applied to several sites, including the upper outer arm, abdomen, buttock, or upper torso. This is an appropriate instruction and part of standard patient teaching for transdermal contraceptive use.
D. "You can continue to use the diaphragm you used before your pregnancy.": The diaphragm often requires refitting postpartum due to changes in vaginal tone and cervix position. Using the same diaphragm without evaluation could reduce effectiveness and increase risk of unintended pregnancy.
Correct Answer is B
Explanation
Rationale:
A. Tenting skin turgor: Tenting indicates dehydration or fluid volume deficit, not overload. It reflects reduced skin elasticity due to poor interstitial fluid volume.
B. Respiratory rate 30/min: Tachypnea can result from pulmonary congestion or edema due to excess fluid in the intravascular space. It is a classic sign of fluid overload as the lungs struggle with impaired gas exchange.
C. Skin warm and dry: Warm, dry skin is a normal finding and does not suggest volume overload. Fluid retention typically causes edema or moist skin in severe cases.
D. Heart rate 60/min: A heart rate within normal range does not point to fluid overload. Often, fluid overload is associated with tachycardia due to increased preload and compensatory responses.
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