A nurse is caring for a client who has a terminal illness and a family member asks why the client's mouth is continually open. Which of the following responses should the nurse make?
The reduced muscle tone relaxed the low muscles
"That happens when a person gets close to death
"I can apply a chin strap to help hold the mouth closed
The Correct Answer is A
A. The reduced muscle tone had relaxed the law muscles CORRECT
Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.
B. "That happens when a person gets close to death INCORRECT
This automatic response is nontherapeutic and does not address the family member's question
C. "I can apply a chin strap to help hold the mouth closed INCORRECT
Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. The client's body should be placed on the floor: This is not a specific cultural practice in Islam. In Islamic tradition, the deceased person is usually placed on a raised surface, like a table or bed, to allow family and friends to gather around for prayers and final respects.
B. The client's oldest child will bathe the body: This is not a specific cultural practice in Islam.
In Islamic tradition, the body is usually washed by individuals of the same gender who are experienced in the ritual washing of the deceased, known as "Ghusl."
C. The client's face should be turned toward Mecca: Correct. In Islamic tradition, when a person dies, it is customary to position the body with the head facing the Kaaba in Mecca, which is the holy city in Islam and the direction toward which Muslims pray.
D. The client's body will be adorned with amulets: This is not a specific cultural practice in Islam. While some individuals in various cultures may use amulets or charms for protection, it is not a universal Islamic practice for the deceased.
Correct Answer is C
Explanation
A. Obscure the client's name with a marker prior to disposal: While obscuring the client's name is better than not doing anything, it does not fully protect their confidential information. The paper could still be read by someone with access to it.
B. Place the paper in a trash can at the nurses' station: This action does not ensure the proper disposal of confidential information. It could be accessible to unauthorized individuals and breach the client's privacy.
C. Shred the paper in a secure container: Correct. Shredding confidential information is the best way to ensure that it cannot be accessed or read by unauthorized individuals.
D. Secure the paper in the nurse's personal locker: While securing the paper in a personal locker is better than leaving it exposed, it is not the most secure method of disposal for confidential
information.
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