A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instruction?

I will use a soft toothbrush or foam swab for oral care.

I will cleanse my mouth after meals with an alcohol-based mouthwash.

I will use a straw when I drink liquids.

I will rinse my mouth frequently with a hydrogen peroxide solution.

None

Answer and Explanation

The Correct Answer is B

Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.

Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.

Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.

Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.

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Correct Answer is C

Explanation

Choice A reason: This is a vague and unhelpful response, because it does not provide any information or reassurance to the client who has a new diagnosis of MS. The nurse should explain the general course of MS and the possible variations among clients.

Choice B reason: This is a sympathetic but incomplete response, because it does not address the client's question or provide any information about the course of MS. The nurse should acknowledge the client's feelings and provide factual and realistic information.

Choice C reason: This is the best response, because it provides accurate and relevant information about the course of MS, which is a chronic and progressive disease that affects the central nervous system. MS can cause acute episodes of neurological symptoms, such as vision loss, numbness, weakness, or fatigue, which are followed by periods of remission, when the symptoms improve or disappear. The length and frequency of the episodes and remissions can vary among clients.

Choice D reason: This is a dismissive and unrealistic response, because it does not answer the client's question or respect the client's right to know about the course of MS. The nurse should not avoid the client's concerns or minimize the impact of the diagnosis. The nurse should help the client cope with the uncertainty and plan for the future.

A. Obtain the prescribed irrigation solution. B. Don personal protective equipment. C. Check the client's pain level. D. Place a waterproof pad under the client's extremity.

Correct Answer is C

Explanation

Choice A reason: This is an important action, but not the first one. The nurse should obtain the prescribed irrigation solution after assessing the client's pain level and providing analgesia if needed.

Choice B reason: This is an important action, but not the first one. The nurse should don personal protective equipment after assessing the client's pain level and providing analgesia if needed.

Choice C reason: This is the correct action, because checking the client's pain level is the first step in the wound care process. The nurse should assess the client's pain level using a valid and reliable pain scale, and administer analgesia as prescribed before irrigating the wound.

Choice D reason: This is an important action, but not the first one. The nurse should place a waterproof pad under the client's extremity after assessing the client's pain level and providing analgesia if needed.

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A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instruction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

Explanation

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