A nurse is collecting data about a client’s oral care. The client wears dentures and reports having mouth sores.
The nurse should identify which of the following oral care practices by the client as a possible cause of the mouth sores?

This action can help to reduce environmental stressors for clients in an acute care unit by limiting noise, crowding, and potential sources of infection.

Visitors should be allowed according to the client’s preference and condition, but excessive or inappropriate visitors should be discouraged.

Choice A is wrong because offering the clients many choices regarding care can increase their stress and anxiety, especially if they are confused, overwhelmed, or unable to make decisions.

The nurse should respect the client’s autonomy and preferences, but also provide guidance and education to help them make informed choices.

Choice C is wrong because assigning different nurses to provide care for clients each day can reduce the continuity and quality of care, as well as the trust and rapport between the client and the nurse.

The nurse should strive to provide consistent and individualized care for each client and establish a therapeutic relationship.

Choice D is wrong because turning on loud music in client care areas can increase environmental stressors for clients in an acute care unit by creating noise pollution, disrupting sleep, and interfering with communication.

The nurse should maintain a quiet and calm environment for the clients and use music only if it is soothing and requested by the client.

The correct answer is choice C. “I will assist you in any way I can during this process.” This response shows sensitivity and respect for the client’s family and their cultural or religious beliefs. Postmortem care involves caring for a deceased patient’s body with dignity and in a manner that is consistent with the patient’s and family’s wishes.The nurse should offer to assist the family in performing the postmortem care if they request to do so.

Choice A is wrong because the family does not need to sign a release form to perform the postmortem care themselves.

There is no legal requirement for this.

Choice B is wrong because a licensed health care worker does not have to perform postmortem care.

The family can perform the care themselves if they wish, with or without the assistance of a health care worker.

Choice D is wrong because postmortem care takes place before the client leaves the facility, not after.

Postmortem care should be provided as soon as possible to prevent tissue damage or disfigurement.