An adult client is admitted with AIDS and oral Candida albicans manifested by several painful mouth ulcers. The nurse delegates to the assistive personnel (AP) and discusses how to assist the client. Which instruction should the nurse provide?
Offer the client mouthwash for thorough cleansing after brushing teeth.
Assist with personal care, but leave oral care for the nurse to complete.
Provide a soft-bristled toothbrush for the client to use during oral care.
Wear sterile gloves when cleansing any areas of infected mucosa.
The Correct Answer is C
Choice A rationale
Offering mouthwash for thorough cleansing after brushing teeth can be too harsh for clients with painful mouth ulcers caused by Candida albicans. It may cause further irritation and discomfort.
Choice B rationale
While assistive personnel can help with personal care, oral care should not be left solely to the nurse. Providing appropriate tools and guidance for the client to perform oral care is essential.
Choice C rationale
Providing a soft-bristled toothbrush is appropriate for clients with oral Candida albicans. It helps in gentle cleaning without causing additional pain or damage to the mucosa.
Choice D rationale
Wearing sterile gloves is not necessary for routine oral care. Clean gloves are sufficient unless there is a specific need for sterility, such as in surgical procedures.
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Correct Answer is A
Explanation
Choice A rationale
Lactulose is a synthetic sugar used to treat hepatic encephalopathy by reducing the absorption of ammonia in the intestines. Ammonia is a neurotoxin that can impair mental status in patients with liver dysfunction. By decreasing ammonia levels, lactulose helps improve cognitive function and mental status in patients with hepatic encephalopathy.
Choice B rationale
While lactulose can cause diarrhea as a side effect, the therapeutic goal in hepatic encephalopathy is not to reduce the number of liquid stools but to lower ammonia levels in the blood. The reduction in ammonia levels leads to improved mental status, not necessarily a reduction in liquid stools.
Choice C rationale
The ability to ambulate independently is not a direct therapeutic response to lactulose. The primary goal of lactulose therapy in hepatic encephalopathy is to improve mental status by reducing ammonia levels, not to enhance physical mobility.
Choice D rationale
Lactulose does not have a direct effect on urine output. Its primary mechanism of action is to reduce ammonia absorption in the intestines, thereby improving mental status in patients with hepatic encephalopathy.
Correct Answer is B
Explanation
Choice A rationale
Teaching anxiety reduction methods for feelings of suffocation is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice B rationale
Increasing the daily intake of oral fluids to liquefy secretions is the most important action for the nurse to instruct the client about self-care. This helps to thin the mucus, making it easier to expectorate and improving breathing.
Choice C rationale
Calling the clinic if undesirable side effects of medications occur is important but not the most immediate action needed to address the client’s respiratory symptoms.
Choice D rationale
Avoiding crowded enclosed areas to reduce pathogen exposure is important but not the most immediate action needed to address the client’s respiratory symptoms.