An older adult reports symptoms of xerostomia. Which of the following interventions should the nurse implement for this patient? (Select all that apply.)
Provide antiseptic mouthwash (such as Listerine) for the patient.
Encourage the patient to brush and floss teeth regularly.
Encourage the patient to drink water frequently.
Provide saliva substitutes.
Correct Answer : B,C,D
Choice A reason: This is incorrect because providing antiseptic mouthwash (such as Listerine) for the patient can worsen xerostomia, or dry mouth. Antiseptic mouthwash can contain alcohol, which can dry out the oral mucosa and reduce saliva production. Saliva is important for lubricating the mouth, preventing infections, and facilitating chewing and swallowing. Therefore, antiseptic mouthwash should be avoided or used sparingly in patients with xerostomia.
Choice B reason: This is correct because encouraging the patient to brush and floss teeth regularly can help prevent dental caries, gingivitis, and periodontitis, which are common complications of xerostomia. Xerostomia can increase the risk of oral infections and tooth decay, as saliva helps wash away food particles, bacteria, and plaque. Therefore, oral hygiene is essential for patients with xerostomia.
Choice C reason: This is correct because encouraging the patient to drink water frequently can help moisten the mouth and relieve the discomfort of xerostomia. Water can also help flush out food debris and bacteria, and prevent dehydration, which can exacerbate xerostomia. Therefore, water intake is beneficial for patients with xerostomia.
Choice D reason: This is correct because providing saliva substitutes can help mimic the functions of natural saliva and improve the symptoms of xerostomia. Saliva substitutes are artificial saliva products that contain water, electrolytes, and lubricants, such as glycerin, carboxymethylcellulose, or xylitol. They can be applied as sprays, gels, rinses, or lozenges, and can help lubricate the mouth, prevent infections, and facilitate chewing and swallowing. Therefore, saliva substitutes are useful for patients with xerostomia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Having stable vital signs does not necessarily mean that the client is not experiencing pain. Vital signs can be affected by various factors, such as medications, stress, or emotions, and may not reflect the true level of pain.
Choice B reason: Holding abdomen tightly is a possible sign of pain, especially if the client had abdominal surgery or has a condition that affects the digestive system. The client may be guarding the painful area or trying to relieve the discomfort.
Choice C reason: Not verbalizing is not a reliable indicator of pain, especially for clients with dementia who may have difficulty communicating or expressing their feelings. The nurse should look for other cues, such as facial expressions, body language, or behavioral changes, to assess the client's pain.
Choice D reason: Moving during sleep is not a specific sign of pain, and may be normal for some clients. However, if the client is restless, agitated, or moaning during sleep, it may indicate that the client is in pain and needs intervention.
Correct Answer is D
Explanation
Choice A reason: Allowing the client to remain in bed but sharing that getting up will be required at least twice a day starting the next morning is not an effective intervention, as it does not address the client's current pain or anxiety, and may increase the client's resistance or fear of mobilization.
Choice B reason: Using the Hoyer lift to get her out of bed so that the knee will not experience much movement and so there will be little pain is not an appropriate intervention, as it does not respect the client's autonomy or preference, and may cause more pain or injury to the knee or other joints.
Choice C reason: Sharing with the client that it is important to get out of bed and that there is pain medication available if it does hurt is not a sufficient intervention, as it does not provide the client with adequate pain relief or reassurance, and may imply that the client's pain is not taken seriously or validated.
Choice D reason: Offering pain medication, administering the medication, and waiting 30 minutes before getting her out of bed is the best intervention, as it provides the client with effective pain management, reduces the client's anxiety, and facilitates the client's mobilization and recovery.
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