A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Relieve the client's pain.

Promote oral hygiene

Ensure adequate nutrition

Prevent aspiration

Answer and Explanation

The Correct Answer is D

A. Relieve the client's pain: While pain management is important for client comfort and recovery, it is not the priority immediately following intermaxillary fixation. Pain relief can be addressed once the more urgent concerns, such as preventing aspiration, are addressed.
B. Promote oral hygiene: Promoting oral hygiene is essential for preventing complications such as infection, but it is not the priority immediately after surgery and intermaxillary fixation. The client's airway and respiratory status should be the primary focus at this time.
C. Ensure adequate nutrition: Ensuring adequate nutrition is important for the client's overall recovery, but it is not the immediate priority after surgery and intermaxillary fixation. The priority is to prevent complications such as aspiration and maintain the client's airway.
D. Prevent aspiration: This is the priority action for the nurse. Intermaxillary fixation restricts the client's ability to open their mouth, increasing the risk of aspiration if vomiting occurs. The nurse should ensure that the client's airway is clear and that measures are in place to prevent aspiration, such as positioning the client appropriately and monitoring for signs of respiratory distress.

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Correct Answer is B

Explanation

A. "There is no way to predict how long it will last in each individual client." This response acknowledges the variability among individuals but does not provide specific information about urinary frequency during pregnancy. While it's true that the duration of urinary frequency can vary from person to person, the response lacks guidance or reassurance for the client.
B. "It occurs during the first trimester and near the end of the pregnancy." This response correctly identifies the pattern of urinary frequency during pregnancy. Urinary frequency is common during the first trimester due to hormonal changes and the growing uterus pressing on the bladder. It may also occur near the end of pregnancy as the fetus descends into the pelvis, putting pressure on the bladder again.
C. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." This response suggests that urinary frequency typically resolves by the 12th week of pregnancy but may persist if the client has poor bladder tone. While urinary frequency may improve for some women after the first trimester, attributing its continuation solely to poor bladder tone oversimplifies the issue.
D. "It’s a minor inconvenience, which you should ignore." This response minimizes the client's concerns and does not provide helpful information about urinary frequency during pregnancy. Urinary frequency can be distressing for some pregnant individuals and should not be dismissed as a minor inconvenience.

A. "My child was born with a birth defect due to an exposure I had overseas" B. "In my dreams, all I can see are the wounded reaching out and trying to grab me" C. "I check any rooms enter because the enemy is still after me and could be hiding anywhere" D. "I killed four enemy soldiers with my bare hands and saved my entire battalion"

Correct Answer is C

Explanation

A. This statement reflects guilt or concern over potential harm to the child, which may be distressing but does not specifically indicate symptoms of PTSD related to combat exposure.
B. This statement describes nightmares or intrusive thoughts related to traumatic events, which are common symptoms of PTSD. The content of the dreams suggests re-experiencing of traumatic events, which is characteristic of PTSD.
C. This statement reflects hypervigilance and paranoia, common symptoms of PTSD. The client's behavior of checking rooms for potential threats indicates a heightened state of arousal and persistent fear related to past combat experiences.
D. While involvement in combat and actions such as killing enemy soldiers may contribute to the development of PTSD, this statement does not directly reflect symptoms of the disorder. Instead, it describes a specific event from the client's military experience. Symptoms of PTSD typically involve re-experiencing, avoidance, negative changes in mood and cognition, and hyperarousal.

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A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

Nursing Test Bank

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A nurse in a prenatal clinic is caring for a client who is at 7 weeks of gestation. The client reports urinary frequency and asks if this will continue until delivery. Which of the following responses should the nurse make?

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Explanation

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Correct Answer is C

Explanation

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