Question 12 type mcsa an older adult patient states

Question 12
Type: MCSA
An older adult patient states, "My mouth is always dry." The nurse recognizes that which priority health
promotion problem should be addressed?
1. Poorly chewed food will remain in the patient’s mouth, supporting bacterial growth.

2. The normal aging process reduces the antibacterial properties of saliva.
3. A lack of salivary gland lubrication makes chewing the food difficult, resulting in gum trauma.
4. A dry mouth lacks bacteria-fighting immunoglobulin A.
Correct Answer: 4
Rationale 1 : While poorly chewed food that remains in the oral cavity does support bacterial growth and a lack of
oral lubrication may make chewing food more difficult, they are not the primary risk factors in this scenario.
Rationale 2 : Normal aging does not appear to have an effect on the antibacterial properties of saliva.
Rationale 3 : There is no indication of gum trauma.
Rationale 4 : Saliva contains large amounts of ions, such as immunoglobulin A, a vital component for destroying
oral bacteria. A lack of saliva increases the risk of infection from oral pathogens.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36-1
Question 13
Type: MCSA
The patient reports feeling pain in the right lower quadrant. The nurse shows an understanding of the anatomical
location of organs in the abdomen by asking the patient which question?
2
Rationale 1 : Problems eating fatty food would relate to the gallbladder, which is located in the right upper
quadrant.
Rationale 2 : The right lower quadrant contains the ascending colon. Discussing bowel habits is indicated.
Rationale 3 : Nausea after eating is not a primary assessment finding associated with the bowels located in the
right lower quadrant.

Rationale 4 : Clamminess after missing a meal could be related to blood glucose abnormalities, which are
associated with the pancreas. The pancreas is located in the left upper quadrant.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 36-1