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 D
Explanation
The correct answer is Choice D
Choice A: Excruciating pain
- Rationale: While partial thickness burns can be painful, especially in the first few days, excruciating pain is less likely for a stable patient 3 days post-burn. Pain management is a crucial aspect of burn care, but excruciating pain might indicate deeper burns or complications like infection.
Choice B: Elevated blood pressure
- Rationale: Elevated blood pressure is not a typical complication of a partial thickness burn. In fact, burn patients are more at risk for hypotension (low blood pressure) due to fluid loss.
Choice C: Compartment syndrome
- Rationale: Compartment syndrome is a serious complication that typically occurs with deep burns or traumatic injuries. It's caused by increased pressure within a muscle compartment, restricting blood flow and potentially leading to tissue death. While a possibility, it's less likely for a partial thickness burn 3 days after the injury.
Choice D: Curling's Ulcer
- Rationale: Curling's ulcer is a peptic ulcer (stomach ulcer) that can develop as a complication of major burns. This is because burns trigger a massive inflammatory response, releasing stress hormones that increase stomach acid production, making the stomach lining more susceptible to ulcers. Given the extensive burn area (30% TBSA) and the timeframe (3 days post-burn), Curling's ulcer becomes a significant concern.
Therefore, the correct answer is: Choice D: Curling's Ulcer
Explanation:
- A 30% TBSA partial thickness burn is a significant injury that triggers a systemic inflammatory response.
- Three days post-burn falls within the timeframe when Curling's ulcer can develop due to the increased stress hormones and gastric acid production.
- While pain management and monitoring for compartment syndrome are important, Curling's ulcer poses a more significant threat in this scenario.
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.
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