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 D
Explanation
The correct answer is choice D. Sit at or below the client’s eye level during feedings.
This action helps the client feel more comfortable and less intimidated by the nurse. It also allows the nurse to observe the client’s swallowing and signs of aspiration more easily.
Choice A is wrong because talking with the client during her feeding can distract her from swallowing properly and increase the risk of aspiration.
The nurse should encourage the client to focus on eating and avoid conversation until the feeding is over.
Choice B is wrong because discouraging the client from coughing during feedings can prevent her from clearing her airway and expelling any food particles that might have entered the trachea.
The nurse should monitor the client for coughing, choking, or changes in voice quality, which are indicators of aspiration.
Choice C is wrong because instructing the client to lift her chin when swallowing can actually make swallowing more difficult and increase the risk of aspiration.
The nurse should instruct the client to tuck her chin when swallowing, which helps close off the trachea and direct food into the esophagus.
Correct Answer is D
Explanation
The correct answer is choice D, spotting.
Placenta previa is a condition where the placenta implants in the lower part of the uterus, partly or completely covering the cervical opening.
This can cause painless, bright red vaginal bleeding, usually in the third trimester.
Spotting is a sign of placenta previa and should be reported to the provider immediately.
Choice A is wrong because nausea is not a specific finding of placenta previa.
Nausea can occur in normal pregnancy or in other conditions such as hyperemesis gravidarum or preeclampsia.
Choice B is wrong because polyhydramnios is not a finding of placenta previa.
Polyhydramnios is a condition where there is too much amniotic fluid in the uterus, which can cause complications such as preterm labor, cord prolapse, or fetal malformations.
Choice C is wrong because uterine tenderness is not a finding of placenta previa.
Uterine tenderness is a sign of abruptio placentae, which is a condition where the placenta separates from the uterine wall before delivery.
This can cause severe abdominal pain, dark red vaginal bleeding, and fetal distress.
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