A Client Has Returned from an Extensive Excision of a Malignant

question 6

Multiple Choice

A client has returned from an extensive excision of a malignant oral tumor. On assessment, the nurse finds the client sitting in a high-Fowler position and complaining of jaw pain. The patient is dusky in color, but vital signs are within normal limits. The priority action by the nurse at this time is to

• A) assess oxygenation status by checking pulse oximetry and lung sounds.
• B) call the physician and anticipate an order for an electrocardiogram (ECG).
• C) have the client rate the pain and then administer the ordered pain medication.
• D) remove the oral packing to assess the surgical incision.

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Definitions:

Fantasies

Imaginative or fanciful thoughts, especially those not based on reality.

Repressions

A defense mechanism where distressing thoughts and feelings are unconsciously excluded from conscious awareness.

Stimulants

Compounds that boost energy, attentiveness, and alertness through the stimulation of the central nervous system activity.

ADHD

Attention Deficit Hyperactivity Disorder, a mental health disorder with symptoms including inattentiveness, hyperactivity, and impulsivity.