The practical nurse (PN) learns that a client who is receiving chemotherapy has developed stomatitis. Which information should the PN obtain from the client during a focused assessment?
Urinary output.
Blood pressure while standing.
Ability to swallow.
Frequency of bowel movements.
The Correct Answer is C
Choice A rationale:
Urinary output is not directly related to stomatitis, which is inflammation of the mouth and throat. While monitoring urinary output is important in many situations, it is not relevant in this case.
Choice B rationale:
Blood pressure while standing is not directly related to stomatitis either. This assessment is more relevant for conditions such as orthostatic hypotension, which can cause a drop in blood pressure upon standing.
Choice C rationale:
Ability to swallow is crucial in the context of stomatitis. Stomatitis can cause painful sores in the mouth, making it difficult for the client to eat or drink. Assessing the client's ability to swallow will help determine the impact of stomatitis on their nutritional intake and overall well-being.
Choice D rationale:
Frequency of bowel movements is unrelated to stomatitis. This assessment is more relevant for gastrointestinal issues or constipation, not for a condition affecting the mouth and throat.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. Coffee-ground secretions draining via nasogastric tube suction.
Choice A rationale:
Oral ice chips eaten 30 minutes after vomiting postoperatively could be considered normal in some cases. However, this finding may not require immediate reporting to the RN unless
other concerning symptoms are present. Choice B rationale:
The inability to void 4 hours after discontinuing an indwelling catheter is not an immediate concern. It's not uncommon for some clients to experience difficulty urinating initially after catheter removal. The client should be closely monitored, and the RN should be informed if the situation persists or worsens.
Choice C rationale:
This is the correct answer because coffee-ground secretions draining via nasogastric tube suction can indicate bleeding in the gastrointestinal tract, potentially from the stomach or esophagus. This finding requires immediate attention as it could be a sign of a serious condition and may require urgent intervention.
Choice D rationale:
Ineffective pain management reported while using morphine PCA is a concern but may not be as critical as the coffee-ground secretions. The PN should still report this finding to the RN for appropriate assessment and possible adjustment of pain management, but it may not warrant immediate reporting.
Correct Answer is B
Explanation
This is the best response for the PN to provide because it sets a clear and firm boundary for the adolescent and discourages inappropriate or sexual comments. The PN should also redirect the adolescent's attention to another topic or activity and document the incident.
A. The size of my breasts is of no concern to you is not the best response because it may sound defensive or sarcastic and may not deter the adolescent from making similar comments in the future.
C. Do you really think so? is not the best response because it may encourage or reinforce the adolescent's inappropriate or sexual comments and may imply that the PN is interested or flattered by them.
D. If you talk like that again, I will tell your parents is not the best response because it may sound threatening or punitive and may not address the underlying issue of the adolescent's behavior. The PN should inform the parents only if the behavior persists or escalates.
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