A nurse is caring for a client who has stomatitis following radiation therapy. Which of the following is an appropriate intervention for the nurse to take?
Serve foods while still at a hot temperature.
Serve foods without sauces or gravies.
Instruct the client to drink liquids without a straw.
Offer mouth rinses with normal saline and water.
The Correct Answer is B
Choice A rationale:
Serving foods while still at a hot temperature (Choice A) is not an appropriate intervention for a client with stomatitis following radiation therapy. Stomatitis can cause inflammation and soreness in the mouth, and hot foods can further irritate the sensitive tissues, leading to increased discomfort and potential injury.
Choice B rationale:
Serving foods without sauces or gravies (Choice B) is the correct choice. Stomatitis often causes pain and discomfort in the mouth, and spicy or acidic foods, as well as those with sauces or gravies, can exacerbate this discomfort. Providing plain and bland foods can help reduce irritation and promote healing in sensitive oral tissues.
Choice C rationale:
Instructing the client to drink liquids without a straw (Choice C) is not a direct intervention for stomatitis. It's more commonly recommended for clients who have undergone oral surgery to prevent dislodging of blood clots. While it's generally a good practice for oral health, it might not significantly impact the discomfort caused by stomatitis.
Choice D rationale:
Offering mouth rinses with normal saline and water (Choice D) is generally a good practice for maintaining oral hygiene, but it might not be the most appropriate intervention for a client with stomatitis following radiation therapy. While rinsing can help keep the mouth clean, it might cause discomfort in the presence of stomatitis due to the potential for mechanical irritation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Hyperventilation, or rapid breathing, is a potential manifestation of hyperglycemia in clients with diabetes mellitus. As blood glucose levels rise, the body attempts to eliminate excess glucose through increased urination. This can lead to dehydration and electrolyte imbalances, potentially resulting in hyperventilation as the body tries to compensate for acidosis. The increased respiratory rate is an attempt to expel carbon dioxide and normalize pH levels. Teaching the client about the connection between hyperglycemia and hyperventilation is crucial, as recognizing this symptom can prompt early intervention.
Choice B rationale:
Cool skin is not a typical manifestation of hyperglycemia. Hyperglycemia usually leads to increased blood flow and warm skin due to the vasodilatory effects of high glucose levels. Cool skin might be more indicative of poor peripheral circulation, but it's not directly related to hyperglycemia.
Choice C rationale:
Metallic taste is not a recognized manifestation of hyperglycemia. Hyperglycemia primarily affects the body's glucose metabolism and can lead to symptoms like increased thirst, frequent urination, and fatigue. Metallic taste is not directly linked to hyperglycemia and might be related to other factors.
Choice D rationale:
Anxiety can be a psychological response to the stress of a new diabetes diagnosis, but it is not a specific manifestation of hyperglycemia. Hyperglycemia-related symptoms are more physiological and metabolic in nature, involving glucose regulation and acid-base balance.
Correct Answer is D
Explanation
Choice A rationale:
Diluting formula with water is not a recommended practice. Formula should be prepared according to the manufacturer's instructions to provide the appropriate balance of nutrients for the newborn. Diluting formula can lead to inadequate nutrition and potential health risks.
Choice B rationale:
Placing the newborn in a side-lying position if vomiting is not advised. Gastroesophageal reflux refers to the backward flow of stomach contents into the esophagus. Placing the newborn in a side-lying position can increase the risk of choking if vomiting occurs. Keeping the baby upright for some time after feeding helps reduce reflux episodes.
Choice C rationale:
Providing a small feeding just before bedtime can exacerbate gastroesophageal reflux. It's recommended to avoid feeding the baby right before bedtime to prevent reflux-related discomfort during sleep. Elevating the head of the crib slightly can also help minimize reflux symptoms.
Choice D rationale:
Positioning the newborn at a 20-degree angle after feeding is a suitable instruction. This position helps prevent or reduce gastroesophageal reflux by allowing gravity to assist in keeping stomach contents down. It's important to hold the baby in an upright position for about 20 to 30 minutes after feeding to facilitate digestion and minimize reflux episodes.
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