A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

Test for the presence of the client's gag reflex.

Lubricate the lips with petroleum jelly.

Place the client in the supine position.

Use a firm toothbrush for tooth and gum care.

Answer and Explanation

The Correct Answer is B

A.   Testing for the gag reflex in an unconscious client may cause discomfort and is not necessary for oral care.
B.   Lubricating the lips with petroleum jelly helps prevent dryness and cracking, maintaining comfort for the unconscious client.

C.   Placing the client in the supine position may increase the risk of aspiration during oral care.
The head should be turned to the side (lateral position) to facilitate drainage.
D.   Using a firm toothbrush may cause injury to the gums and oral tissues. A soft toothbrush is more appropriate for oral care in unconscious clients.

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Correct Answer is D

Explanation

A. While some clients may be receptive to a scientific perspective, cultural beliefs and practices can significantly influence health-related decisions and behaviors.
B. Assigning clients to specific cultural categories can lead to stereotyping and may not account for the individual variations within a cultural group.
C. Disease and illness can indeed be influenced by cultural factors, including beliefs about health and healing practices.

D. The meaning of behavior can vary widely across cultures, and understanding the cultural context is crucial for providing culturally competent care.

A. The client's belief that his needs will be met through education B. The client seeking family approval by agreeing to a teaching plan C. The nurse explaining the need for education to the client D. The nurse's empathy about the client having to self-inject

Correct Answer is A

Explanation

A. The client's belief that his needs will be met through education reflects intrinsic motivation, which is likely to enhance the client's commitment to learning and self-care.
B. Seeking family approval may be a motivator, but it is an external factor, and intrinsic motivation is generally more effective for sustained behavior change.
C. While the nurse explaining the need for education is important, the client's personal belief and understanding of the value of education are key for motivation.
D. The nurse's empathy is essential for building rapport, but the client's belief in the benefits of education is more directly related to motivation.

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A nurse is caring for a client who is unconscious. Which of the following actions is appropriate for the nurse to take when providing the client's oral care?

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Naxlex Comprehensive Predictor Exams

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