Which action will the nurse take when assessing a patient with possible oral cancer?
Palpate over the maxillary sinuses.
Ask about a productive cough.
Observe for purulent nasal drainage.
Check the mouth for leukoplakia.
The Correct Answer is D
Choice A rationale
Palpating over the maxillary sinuses is not typically associated with oral cancer assessment. This action is more relevant to sinus issues and does not provide information about oral cancer.
Choice B rationale
Asking about a productive cough can be relevant in assessing respiratory conditions but is not a direct method for evaluating oral cancer. Oral cancer symptoms are more localized to the mouth area.
Choice C rationale
Observing for purulent nasal drainage is not a standard action in assessing for oral cancer. Nasal drainage would be more indicative of sinus or respiratory issues, not oral pathology.
Choice D rationale
Checking the mouth for leukoplakia is a key action when assessing for oral cancer. Leukoplakia presents as thickened, white patches inside the mouth and can be precancerous, making it a critical observation in potential oral cancer cases.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Monitoring calcium levels is important after administering calcium gluconate IV, but it is not the primary indicator of the medication's effectiveness in treating hyperkalemia. Calcium gluconate is used in hyperkalemia to stabilize the heart muscle, not to correct calcium levels.
Choice B rationale
Neurologic status may be affected by hyperkalemia, but changes in neurologic status are not the most direct measure of calcium gluconate's effectiveness. The medication's primary role is to address cardiac risks associated with high potassium levels.
Choice C rationale
Cardiac rhythm is the most critical aspect to monitor after administering calcium gluconate for hyperkalemia. Hyperkalemia can cause life-threatening cardiac dysrhythmias, and calcium gluconate works by stabilizing the cardiac membrane, thus the effectiveness of the treatment is directly reflected in the stabilization of the cardiac rhythm.
Choice D rationale
While urine volume can indicate kidney function and might indirectly reflect changes in potassium levels, it is not the direct measure of calcium gluconate's effectiveness in the emergency treatment of hyperkalemia.
Correct Answer is C
Explanation
Choice A rationale
Hemorrhage refers to bleeding, which can be a serious complication of peptic ulcer disease but does not lead to the spilling of gastric contents into the peritoneal cavity.
Choice B rationale
Dumping syndrome is a condition where food moves too quickly from the stomach to the small intestine, which can cause symptoms like nausea and abdominal pain, but it does not involve the leakage of gastric contents into the peritoneal cavity.
Choice C rationale
Perforation is the correct answer because it describes a hole forming in the wall of the stomach or duodenum, allowing gastric contents to spill into the peritoneal cavity, leading to peritonitis, which is a severe and life-threatening condition.
Choice D rationale
Gastric outlet obstruction is a blockage at the end of the stomach that prevents contents from entering the small intestine, which can cause vomiting and abdominal pain, but it does not result in the leakage of gastric contents into the peritoneal cavity.
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