The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?
Risk for infection
Ineffective airway clearance
Acute pain
Disturbed body image
The Correct Answer is B
The correct answer is choice B. Ineffective airway clearance.
Choice A rationale:
Risk of infection is not the priority nursing problem in this scenario. While the darkened membranes and smoky breath may be indicative of potential infection, addressing ineffective airway clearance is more urgent as it directly impacts the client's breathing and oxygenation.
Choice B rationale:
Ineffective airway clearance should be the priority nursing problem. Darkened membranes of the mouth and smoky breath suggest possible inhalation injury or airway obstruction.
Maintaining a patent airway is crucial for adequate oxygenation and to prevent further complications.
Choice C rationale:
Acute pain is not the priority nursing problem in this case. Although it is essential to address any discomfort the client may be experiencing, it takes a back seat to the more critical issue of ineffective airway clearance.
Choice D rationale:
Disturbed body image is not the priority nursing problem when the client has darkened mouth membranes and smoky breath. While it is important to address body image concerns, the immediate focus should be on managing and improving the client's airway clearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is Choice B. Refer to the dermatologist for prescribed long-term therapy. Choice A rationale:
Omitting specific foods like chocolate, carbonated drinks, and fried foods from the diet is a common misconception about acne management. While a healthy diet can contribute to overall skin health, there is no direct evidence to support the notion that avoiding these foods alone will effectively treat acne. Acne is a complex skin condition influenced by various factors, including hormonal imbalances and genetics.
Choice B rationale:
Referring the client to a dermatologist for prescribed long-term therapy is the most appropriate recommendation for managing acne. Dermatologists are medical professionals specialized in skin conditions and can provide personalized treatment plans based on the client's specific type and severity of acne. They may prescribe topical or oral medications, such as retinoids, antibiotics, or hormonal therapy, to effectively manage acne.
Choice C rationale:
Expressing blackheads and using an exfoliating scrub is not a recommended approach for managing acne. Manual extraction of blackheads can lead to skin irritation, infection, and scarring. Exfoliating scrubs can also cause damage to the skin, especially if used too frequently or if the acne is inflamed.
Choice D rationale:
Washing the hair and skin daily with mild soap and warm water is a general hygiene recommendation and may help to keep the skin clean, but it is not a specific and effective treatment for acne. Acne requires targeted therapies to address its underlying causes and manage its symptoms.
Correct Answer is A
Explanation
The correct answer is Choice A:
"Determine home navigational safety hazards.”. Choice A rationale:
The PN should first assess the client's home for safety hazards that may be contributing to the client's unsteadiness and increased fall risk. Identifying and addressing these hazards can help create a safer environment for the client and potentially prevent accidents.
Choice B rationale:
Encouraging the client to obtain a medical alert device is not the immediate priority in this situation. Addressing the client's safety and identifying potential hazards should be the first step before considering additional measures like medical alert devices.
Choice C rationale:
Recommending that the client obtain a walker is premature without first assessing the home
environment and determining if there are any correctable safety issues. The PN should prioritize safety assessment before recommending any assistive devices.
Choice D rationale:
While maintaining the client's privacy is important, it is not the most urgent action in this scenario. The priority is to assess the client's safety and identify potential hazards in the home. Privacy concerns can be addressed afterward.
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