A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following actions should the nurse take?

Provide the client with an alcohol-based mouthwash.

Instruct the client to brush their remaining teeth with a firm toothbrush.

Advise the client to rinse their mouth and dentures after each meal.

Swab the client's mouth with lemon-glycerin sponges at bedtime.

Answer and Explanation

The Correct Answer is C

A. Provide the client with an alcohol-based mouthwash: Alcohol-based mouthwashes can cause oral mucosa dryness and irritation, worsening mouth pain. They are not recommended for clients with oral discomfort or partial dentures.

B. Instruct the client to brush their remaining teeth with a firm toothbrush: A firm toothbrush can damage gum tissue and increase discomfort, especially in a client already experiencing pain. A soft-bristled toothbrush is safer for maintaining oral hygiene without causing trauma.

C. Advise the client to rinse their mouth and dentures after each meal: Rinsing after meals removes food particles and prevents bacterial buildup, reducing irritation and risk of infection. This promotse oral health and comfort in clients with partial dentures.

D. Swab the client's mouth with lemon-glycerin sponges at bedtime: Lemon-glycerin swabs can dry out the mucous membranes and cause irritation. They are no longer recommended in oral care because they worsen discomfort rather than relieve it.

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Correct Answer is A

Explanation

A. Use a reflex hammer: Clonus is assessed by using a reflex hammer to test deep tendon reflexes, typically at the ankle joint. Sustained rhythmic contractions following dorsiflexion of the foot confirm the presence of clonus, which often indicates upper motor neuron dysfunction.

B. Administer magnesium sulfate: Magnesium sulfate is a treatment used in conditions such as preeclampsia with severe features but is not a method of assessment. Medication administration would come after clonus has been identified, not during the diagnostic step.

C. Perform a Romberg test: The Romberg test assesses balance and proprioception, often used in neurological exams for cerebellar or sensory dysfunction. It does not evaluate for clonus, which specifically relates to abnormal reflex activity.

D. Test the gait for symmetry: Gait assessment provides information about coordination, strength, and balance. While it may reveal neurologic impairment, it does not directly test for clonus or identify the rhythmic contractions associated with it.

A. Move the client using a slider board. B. Use an air-assisted transfer device to move the client. C. Raise the bed to 5 cm (2 in) above the level of the stretcher. D. Position the head of the bed at 25° prior to the transfer.

Correct Answer is B

Explanation

A. Move the client using a slider board: A slider board can assist with lateral transfers, but for a client weighing 136 kg (300 lb), it may not provide the safest method due to the increased risk of strain and injury to staff. A more advanced device is preferred.

B. Use an air-assisted transfer device to move the client: An air-assisted transfer device is the safest choice for bariatric clients because it significantly reduces friction, making movement easier and safer for both the client and healthcare workers. It minimizes musculoskeletal injury risk during transfer.

C. Raise the bed to 5 cm (2 in) above the level of the stretcher: The bed should be adjusted to the same height as the stretcher to allow a smooth transfer. Raising it higher can make the transfer unsafe and increase the risk of injury or difficulty sliding the client across.

D. Position the head of the bed at 25° prior to the transfer: The head of the bed should be flat during lateral transfers to maintain spinal alignment and ease movement. Elevating the head complicates the process and increases the chance of shear or strain.

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A nurse is assessing a client who wears partial dentures and reports mouth pain. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has suspected clonus. Which of the following actions should the nurse take to assess for this condition?

Correct Answer is A

Explanation

A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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