A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible.
Which of the following is an appropriate action by the nurse?
Suggest rinsing his mouth with an alcohol-based mouth wash.
Instruct the client on the use of esophageal speech.
Offer the client saltine crackers between meals.
Provide humidification of the room air.
The Correct Answer is D
Provide humidification of the room air. This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.
Choice A is wrong because rinsing the mouth with an alcohol-based mouth wash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.
Choice B is wrong because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia.
Esophageal speech involves swallowing air into the esophagus and releasing it to create sound.
It has nothing to do with saliva flow or dry mouth.
Choice C is wrong because saltine crackers are dry and hard to swallow without adequate saliva.
They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.
Normal ranges for saliva flow vary depending on the method of measurement, but generally, a stimulated saliva flow rate of less than 0.7 mL/min or an unstimulated saliva flow rate of less than 0.1 mL/min is considered indicative of xerostomia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Arching should not be expected. Arching of the body is not a typical manifestation of bacterial pneumonia. It may be seen in infants with certain conditions such as abdominal pain or neurologic issues, but it is not specific to pneumonia.
Choice B reason:
Drooling should not be expected. Drooling is not a common manifestation of bacterial pneumonia. It may be seen in certain conditions affecting the throat or mouth, but it is not directly related to pneumonia.
Choice C reason:
Fever is the correct answer. Bacterial pneumonia is an infection in the lungs caused by bacteria. When a child has bacterial pneumonia, their body's immune system responds to the infection, leading to inflammation and fever.
Choice D reason:
Steatorrhea should not be expected. Steatorrhea refers to fatty, bulky, and foul-smelling stools and is not associated with bacterial pneumonia. Steatorrhea may be seen in conditions affecting the gastrointestinal system and fat absorption.
Choice E reason:
Tinnitus should not be expected. Tinnitus is the perception of noise or ringing in the ears and is not a typical manifestation of bacterial pneumonia. Tinnitus can be associated with various ear-related conditions or medication side effects, but it is not directly related to pneumonia.
Correct Answer is A
Explanation
The correct answer is choice A. A client who is ambulatory and receiving oxygen should be evacuated first during a fire because they are at risk of fire and explosion from the oxygen source. The nurse should instruct the staff to turn off the oxygen supply, remove the oxygen device from the client, and assist them to walk out of the building using the nearest exit.
Choice B is wrong because a client who uses a wheelchair and is confused is not in immediate danger from the fire. They can be evacuated using a swing carry or an extremity carry by two staff members after the clients who are more vulnerable are evacuated.
Choice C is wrong because a client who is bedridden and wears a hearing aid is not in immediate danger from the fire. They can be evacuated using a cradle drop by one staff member after the clients who are more vulnerable are evacuated.
Choice D is wrong because a client who has a fracture and is in balance suspension traction is not in immediate danger from the fire. They can be evacuated using a special device such as a sked or a sled by two or more staff members after the clients who are more vulnerable are evacuated.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.