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)