EXAM 2: chapter 53

The nurse admits an immunocompromised client who has contracted herpes simplex stomatitis. The nurse anticipates that the health care provider will request which medication? Acyclovir (Zovirax) Diphenhydramine (Benadryl) Nystatin (Mycostatin) Tetracycline syrup (Sumycin syrup)

Acyclovir (Zovirax) The nurse anticipates that the health care provider will request acyclovir for the client. Acyclovir (Zovirax) is an antiviral agent that is prescribed for immunocompromised clients who contract herpes simplex stomatitis.Diphenhydramine is an antihistamine that is not indicated for treating this condition. Nystatin is indicated for treatment of fungal infection. Tetracycline syrup is indicated for treatment of recurrent aphthous ulcers (canker sores).

A client has undergone a partial glossectomy for cancer. What community resource does the nurse refer the client to when dressing supplies will be needed at home? Oral Cancer Foundation American Cancer Society (ACS) Client Advocate Foundation American Medical Supply Foundation

American Cancer Society (ACS) The ACS supplies dressings and transportation to and from follow-up visits or medical treatments for clients with cancer. A partial glossectomy is removal of part of the tongue (see Chapter 29).The Oral Cancer Foundation is an organization for local support groups and resources. The Client Advocate Foundation provides education, legal counseling, and referrals to clients with cancer and survivors concerning managed care, insurance, financial issues, job discrimination, and debt crisis matters. The American Medical Supply Foundation does not exist.

A client with oral carcinoma has a priority problem of risk for airway blockage related to obstruction by the tumor. At the beginning of the shift, which action will the nurse take first? Suction the client's oral secretions to clear the airway. Place the client on humidified oxygen per nasal cannula. Assist the client to an upright position to facilitate breathing. Assess the respiratory effort and quantities and types of oral secretions.

Assess the respiratory effort and quantities and types of oral secretions. The nurse would first assess the client's respiratory effort and quantities and types of oral secretions. Assessment is the first step of the nursing process.Suctioning the client, placing the client on humidified oxygen, and assisting the client to an upright position are not the first steps in the nursing process. These interventions may or may not be necessary if the nurse follows the nursing process.

The nurse is caring for a client diagnosed with aphthous ulcers. The nurse instructs the client to avoid which foods? Select all that apply. Apples Bananas Cheese Nuts Potatoes

Cheese Nuts Potatoes Aphthous ulcers (canker sores) are small, shallow lesions that develop on the soft tissues in the mouth or at the base of the gums. The nurse tells the client that certain foods such as cheese, nuts, and potatoes may trigger allergic responses that cause aphthous ulcers and should be avoided.Apples and bananas are not acidic and do not trigger allergic responses that cause aphthous ulcers.

As a result of being treated with radiation for oral cancer, a client is experiencing xerostomia. What collaborative resource does the nurse suggest for this client's care? Dentist Occupational therapist Psychiatrist Speech therapist

Dentist Xerostomia is the subjective feeling of oral dryness, which is often (but not always) associated with hypofunction of the salivary glands. It is a long-term effect of radiation therapy and requires ongoing oral care such as the use of saliva substitutes and follow-up dental visits.Occupational therapists, psychiatrists, and speech therapists are not the appropriate resource for a client with xerostomia.

When caring for a client with oral cancer who has developed stomatitis as a complication of radiation and chemotherapy, which action does the nurse delegate to the unlicensed assistive personnel (UAP)? Provide oral care using disposable foam swabs. Inspect the oral mucosa for evidence of oral candidiasis. Instruct the client on how to use nystatin (Mycostatin) oral rinses. Teach the client how to make appropriate dietary choices.

Provide oral care using disposable foam swabs. Providing oral care for a client with oral lesions is an appropriate assignment for a UAP.Assessments, client teaching, and assisting clients with oral problems in making appropriate dietary choices are the responsibilities of licensed nursing staff.

A client with oral cancer is depressed over the diagnosis and tells the nurse of plans to have a radical neck dissection. What is the nurse's best reaction? Listen to the client and then explain that it is normal to feel depressed about the diagnosis. Explain the grieving process and listen to what the client has to say. Suggest that the client talk with friends and family and seek their support. Listen to the client's concerns and feelings and then suggest that the client join a community group of cancer survivors.

Listen to the client's concerns and feelings and then suggest that the client join a community group of cancer survivors. The nurse's best reaction is to listen to the client and suggest a community support group of those with similar diagnoses who can offer support to the client.Telling the client that his or her feelings are normal or explaining the grieving process to the client are not helpful or therapeutic; the client needs more guidance. The nurse should not assume that the client's family and friends are an appropriate support group, because this may not be the case.

A client has recently developed acute sialadenitis. Which intervention does the nurse include in this client's care? Applying cold compresses Avoiding the use of fruit or citrus-flavored candy Massaging the salivary gland Restrict fluids

Massaging the salivary gland Sialadenitis (sialoadenitis) is inflammation of a salivary gland. The salivary gland is massaged to stimulate the flow of saliva. This is done by milking the edematous gland with the fingertips toward the ductal opening.To promote the flow of saliva, warm, not cold, compresses are applied to the affected salivary gland. Sialagogues such as lemon slices and fruit- or citrus-flavored candy are used to stimulate the flow of saliva. The client is kept well hydrated to promote salivary flow.

The nurse is caring for a postoperative client who had an extensive oral and neck surgery. The client is now describing throbbing pain in the head. The nurse anticipates that the health care provider will request which medication for this client? Diphenhydramine (Benadryl) Midazolam (Versed) intravenously Morphine sulfate intravenously Oxycodone plus acetaminophen (Percocet, Tylox)

Morphine sulfate intravenously Intravenous morphine sulfate is indicated for severe pain and is given initially. Clients undergoing surgery for oral cancer describe their pain as throbbing or pounding.Diphenhydramine is an anti-inflammatory agent and is not indicated for treatment of pain. Midazolam is used for conscious sedation and is not indicated for pain. Oxycodone/acetaminophen is given for systematic relief of moderate pain. This client may also have trouble swallowing.

Which practice does the nurse include when teaching a client about proper oral care? Perform self-examination of the mouth every week, and report any unusual findings. Brush the teeth daily and floss as needed. Use drugs that reduce the flow of saliva unless lesions are present. Regularly rinse mouth with alcohol-based agent.

Perform self-examination of the mouth every week, and report any unusual findings. The nurse needs to teach the client that proper oral care involves self-examination of the mouth every week and reporting any unusual findings to the Health Care Provider.Clients need to brush teeth and floss every day. Clients would be instructed to avoid, if possible, drugs that can cause inflammation of the mouth or that can reduce the flow of saliva, and to avoid contact with agents that may cause inflammation of the mouth (such as alcohol based mouthwashes).

The nurse is instructing a client on measures to maintain effective oral health. Which measures does the nurse include in the client's teaching plan? Select all that apply. Regular dental checkups Use of mouthwashes containing alcohol Ensuring that dentures are slightly loose-fitting Managing stress as much as possible Eating a balanced diet

Regular dental checkups Managing stress as much as possible Eating a balanced diet Regular dental checkups are important so potential problems can be prevented or attended to promptly. Stress suppresses the immune system, which can increase the client's risk for infections such as Candida albicans. Eating a balanced diet can reduce the risk for dental caries and infections such as C. albicans or stomatitis.Mouthwashes that contain alcohol may cause inflammation and should be avoided. Dentures must be in good repair and need to fit properly. (Chart 53-1)

The nurse is providing instructions to a client who has a history of stomatitis. Which instructions does the nurse include in the client's teaching plan? Encourage the client to eat acidic foods to decrease bacteria. Mouth care should be performed twice daily. Rinse the mouth with warm saline or sodium bicarbonate. Use a medium-bristled toothbrush for oral care.

Rinse the mouth with warm saline or sodium bicarbonate. Rinsing the mouth with warm saline or sodium bicarbonate or a combination of the two decreases inflammation and pain.Acidic foods increase inflammation and should be avoided. Mouth care should be done after each meal and as often as needed. If stomatitis is not controlled, mouth care may have to be done every 2 hours or more frequently. A soft toothbrush not medium-bristled one would be used for oral care.

Which food does the nurse instruct a client undergoing chemotherapy for oral cancer with secondary stomatitis to avoid? Broiled fish Ice cream Salted pretzels Scrambled eggs

Salted pretzels Salty foods like pretzels can further irritate ulcers in the client's mouth, causing pain.Cool or cold foods and foods high in protein, such as fish, eggs, and ice cream, may be included in the diet of the client with stomatitis.

A client who has undergone surgery and completed radiation therapy to treat oral cancer reports persistent dry mouth. What will the nurse teach this client about managing this symptom? Use saliva substitutes, especially when eating dry foods. This condition is common but is temporary. Use lozenges and hard candies to prevent dry mouth. This indicates a complication of therapy.

Use saliva substitutes, especially when eating dry foods. Xerostomia is a common effect of oral irradiation and may be permanent. Clients should be advised to use saliva substitutes.The condition is common, but often permanent. Lozenges and hard candies are not as effective as saliva substitutes. Dry mouth is a side effect of therapy, not a symptom of complications. Frequent sips of water is the preferred method of treating xerostomia during radiation therapy.