ATI Care of Patients
with Oral Cavity Problems, Questions and Answers with Explanations, 100%
Correct, Download to Score A
Test Bank
MULTIPLE CHOICE
1. The nurse is caring for a client who is being discharged
following surgery for oral cancer. Which sign is the client instructed to watch
for that indicates possible metastasis of the cancer?
a. Fragile
gums that bleed easily
b. White
patches on the tongue and the back of the throat
c. Painful
ulcerated lesions on the gums or inside of the cheek
d. Small
hard lumps on the side of the neck or under the chin
ANS: D
Cervical lymph nodes that become hardened, enlarged, and
fixed in position are indications of metastatic disease. An older adult or a
client with a dry mouth may develop fragile gums that bleed easily. White
patches on the tongue and the back of throat could be leukoplakia—precancerous
lesions that are normally benign. Stomatitis or inflammation of the oral cavity
can lead to fragile gums, white patches (candidiasis), and painful open sores
throughout the oral cavity, but these conditions are not cancerous.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Health Promotion and Maintenance
(Health Screening)
MSC: Integrated Process: Nursing Process (Implementation)
2. The nurse is caring for a female client who has just
undergone excision of a parotid gland tumor. The client tells the nurse that
she is experiencing facial weakness on the operative side. Which is the nurse’s
best response?
a. “You may
be experiencing a slight stroke, and I will notify the doctor.”
b. “This is
a temporary condition that will resolve once radiation treatment is begun.”
c. “You are
experiencing weakness because the facial nerve was irritated during the
surgery.”
d. “You
probably have a pinched nerve after lying on the operating room table for so
long.”
ANS: C
Cranial nerve V involvement is a possible outcome of this
type of surgery. The client presents with facial weakness and possibly with
loss of sensation to the affected side. The other choices regarding facial
weakness following this type of surgery are not accurate.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Physiological Integrity
(Reduction of Risk Potential—Potential for Complications from Surgical
Procedures and Health Alterations)
MSC: Integrated Process: Nursing Process (Implementation)
3. The nurse is caring for a client who is receiving
radiation therapy for treatment of oral cancer. The client reports a constant
dry mouth. Which is the nurse’s best response?
a. “Massage
the area just over the lower jaw twice a day.”
b. “Use
lemon and glycerin swabs to clean your mouth and help keep it moist.”
c. “Suck on
lemon slices to help increase saliva production.”
d. “Rinse
your mouth out often with warm saline or sodium bicarbonate solution.”
ANS: D
Clients should avoid agents that can irritate the oral
mucosa and should keep their mouth moist with frequent rinses of warm saline or
sodium bicarbonate solution. Massage is recommended only for acute
sialadenitis—inflammation of a salivary gland. Lemon slices and lemon and
glycerin swabs are acidic and can further dry the mucosa, causing a burning
sensation. The use of lemon slices after radiation therapy is discontinued may
promote saliva production.
DIF: Cognitive Level: Comprehension/Understanding REF: p.
1197
TOP: Client Needs Category: Physiological Integrity (Basic
Care and Comfort—Non-Pharmacological Comfort Interventions)
MSC: Integrated Process: Nursing Process (Implementation)
4. The nurse is caring for a client who has just received a
diagnosis of advanced oral cancer and has learned that a glossectomy with jaw
resection will have to be scheduled. The client states to the nurse, “I would
rather die than have half of my face removed. My life is over.” Which is the
best description of the client’s response to the diagnosis?
a. Refusal
of any more treatment
b. Grief
over the diagnosis
c. Acceptance
of the diagnosis
d. Denial
about the diagnosis
ANS: B
The client is grieving the loss of his health and present
appearance. Because the client has just learned of the diagnosis and treatment,
the client is reacting in a negative way. This behavior demonstrates grief, not
necessarily refusal of treatment, nor denial or acceptance of the diagnosis.
DIF: Cognitive Level: Comprehension/Understanding REF: p.
1200
TOP: Client Needs Category: Psychosocial Integrity (Grief
and Loss)
MSC: Integrated Process: Nursing Process (Assessment)
5. The nurse is caring for a client who has just received a
diagnosis of advanced oral cancer that will require extensive surgery. Which
statement by the client indicates that the diagnosis is accepted?
a. “The
biopsy test results will be confirmed again next week.”
b. “Of all
the bad things to happen to me, now I have cancer on top of it all.”
c. “If I
can live long enough to see my son get married, everything will be alright.”
d. “I don’t
like it, but I have cancer and that’s the way it is.”
ANS: D
The client has accepted the diagnosis. He is not happy about
it but has acknowledged the reality of the situation. The other responses indicate
denial, anger, or bargaining responses to the diagnosis.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Psychosocial Integrity (Coping
Mechanisms)
MSC: Integrated Process: Nursing Process (Assessment)
6. The nurse is caring for a client who just had a radical
jaw and neck resection. The nurse is developing a teaching plan for the client
and spouse about care after discharge from the hospital. Which is an effective
teaching objective for this client and spouse?
a. The
client’s spouse will be able to change the client’s tracheostomy ties correctly
after three teaching sessions.
b. The
client and spouse will verbalize the signs of readiness for oral feedings
following placement of the tracheostomy.
c. The
client’s spouse will correctly administer the client’s tube feedings twice
daily.
d. The
client and spouse will understand incision care and the importance of infection
prevention.
ANS: A
The objective is action oriented, specific, achievable, and measurable.
The other responses are not as clear and measurable.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Health Promotion and Maintenance
(Principles of Teaching/Learning)
MSC: Integrated Process: Teaching/Learning
7. The nurse is caring for a client who just had a radical
jaw and neck resection for oral cancer. The nurse has just completed teaching
for the spouse and client about tracheostomy care. Which notation in the
client’s chart is the most accurate documentation of the teaching that
occurred?
a. “The
client and spouse were instructed regarding management of mucous plugs and
thick secretions.”
b. “Information
about home oxygen therapy and equipment was provided for the client and
spouse.”
c. “The
client and spouse were shown how to suction the tracheostomy and change the
ties.”
d. “Correct
suctioning procedure was demonstrated, and the client’s spouse verbalized two
instances when suctioning needs to occur.”
ANS: D
The documentation should include teaching actions, as well
as the spouse’s response to the instructions. The other choices do not indicate
the response by the client and spouse to the teaching. A return demonstration
would be beneficial.
DIF: Cognitive Level: Application/Applying or higher REF:
N/A
TOP: Client Needs Category: Health Promotion and Maintenance
(Principles of Teaching/Learning)
MSC: Integrated Process: Nursing Process (Evaluation)
Category | ATI |
Release date | 2021-09-14 |
Pages | 10 |
Language | English |
Comments | 0 |
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