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Question 12Type: MCSAAn 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: 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 immunoglobulinA, a vital component for destroying oral bacteria. A lack of saliva increases the risk of infection from oral pathogens.4Global Rationale: Cognitive Level: ApplyingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 36-1Question 13Type: MCSAThe 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
Global Rationale: Cognitive Level: ApplyingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 36-1