An adult patient is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates oral care to the unlicensed assistive personnel (UAP) and discusses how to assist the patient.
Which instruction should the nurse give to the UAP?
Wear sterile gloves when cleansing any areas of infected mucosa.
Assist with personal care, but leave oral care for the nurse to complete.
Provide a soft-bristled toothbrush for the patient to use during oral care.
Offer the patient mouthwash for thorough cleansing after brushing teeth.
The Correct Answer is C
Choice A rationale:
Sterile gloves are not necessary for routine oral care, even in the presence of oral Candida albicans.
Standard precautions, which include the use of gloves, are sufficient to protect the UAP from exposure to blood and body fluids.
Sterile gloves would only be indicated for invasive procedures, such as oral surgery or deep tissue sampling.
Choice B rationale:
Delegating oral care to the UAP is appropriate, as it is a routine task that does not require the specialized skills of a nurse.
The nurse should provide clear instructions to the UAP on how to perform oral care, but it is not necessary for the nurse to complete the task themselves.
Choice C rationale:
Using a soft-bristled toothbrush is important for patients with oral Candida albicans, as it can help to remove plaque and debris without further irritating the delicate tissues of the mouth.
A soft-bristled toothbrush is less likely to cause bleeding or pain than a harder-bristled toothbrush.
Choice D rationale:
Mouthwash is not typically recommended for patients with oral Candida albicans, as it can actually dry out the mouth and worsen symptoms.
In some cases, a healthcare provider may prescribe a special antifungal mouthwash, but this should only be used under their supervision.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Autoimmune responses occur when the immune system mistakenly attacks the body's own tissues. They are not typically triggered by allergens like bee stings.
Autoimmune responses often develop slowly over time and present with symptoms related to the specific tissues being attacked.
The rapid onset of symptoms in this case, along with the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of an autoimmune response.
Choice B rationale:
Type II hypersensitivity reactions involve antibodies that target and destroy cells or tissues. These reactions often take hours or days to develop, rather than minutes.
Examples of type II hypersensitivity reactions include transfusion reactions, hemolytic disease of the newborn, and some autoimmune diseases.
The rapid onset of symptoms in this case is not consistent with a type II hypersensitivity reaction.
Choice C rationale:
Cell-mediated hypersensitivity reactions involve T cells that directly attack cells or tissues. These reactions typically take 1-3 days to develop.
Examples of cell-mediated hypersensitivity reactions include contact dermatitis (e.g., poison ivy), graft-versus-host disease, and some drug reactions.
The rapid onset of symptoms in this case, as well as the specific symptoms of rash, shortness of breath, and low blood pressure, are not characteristic of a cell-mediated hypersensitivity reaction.
Choice D rationale:
IgE response hypersensitivity reactions are the most immediate type of allergic reaction.
They are mediated by immunoglobulin E (IgE) antibodies, which bind to mast cells and basophils.
When an allergen (like bee venom) cross-links IgE antibodies on mast cells, it triggers the release of histamine and other inflammatory mediators.
These mediators cause vasodilation, increased vascular permeability, smooth muscle contraction, and mucus secretion, leading to the characteristic symptoms of an allergic reaction.
The rapid onset of symptoms in this case, including rash, shortness of breath, and low blood pressure, are consistent with an IgE-mediated hypersensitivity reaction.
Correct Answer is D
Explanation
Choice A rationale:
Observing the skin for lesions is not a specific technique for assessing early signs of rheumatoid arthritis. While RA can sometimes manifest with skin lesions, they are not typically present in the early stages of the disease. Moreover, skin lesions can be indicative of a wide range of other conditions, making them a less reliable indicator of RA.
Choice B rationale:
Palpating the lymph nodes is also not a specific technique for assessing early signs of rheumatoid arthritis. Lymph node enlargement can occur in various inflammatory conditions, including infections and autoimmune diseases. It is not a characteristic feature of early RA.
Choice C rationale:
Palpating large joints for nodules is a technique used to assess for rheumatoid arthritis, but it is more likely to detect nodules in later stages of the disease. Nodules are typically firm, non-tender bumps that develop under the skin around joints. They are often found in areas like the elbows, knuckles, and fingers. However, they may not be present in the early stages of RA.
Choice D rationale:
Observing the client's fingers is the most appropriate technique for assessing early signs of rheumatoid arthritis. This is because the fingers are often the first joints to be affected by the disease. Early signs of RA in the fingers can include:
Swelling of the finger joints, particularly the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. Tenderness and pain in the finger joints, especially upon movement.
Stiffness in the finger joints, which is often worse in the mornings and after periods of inactivity. Redness or warmth in the finger joints.
Difficulty bending or straightening the fingers.
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