In a long-term care facility, a nurse is having a discussion with the nurse aides about ways to deal with dementia clients who are uncooperative with mouth care. Appropriate methods to use include which of the following?
Having another nurse aide assist in holding the client’s mouth open with a tongue depressor
Involving the client in the process of oral hygiene, such as using the hand-over-hand technique to brush the client's teeth
Speaking to the client sternly and instructing the client to open their mouth and cooperate immediately
Quickly performing oral hygiene without explanation since the client is uncooperative
The Correct Answer is B
Choice A reason: This method is not appropriate because it can cause physical and psychological harm to the client. It can injure the client's mouth, trigger a gag reflex, or cause choking. It can also make the client feel violated, frightened, or angry. This can worsen the client's behavior and damage the trust between the client and the caregiver.
Choice B reason: This method is appropriate because it can help the client maintain their dignity, autonomy, and sense of control. It can also stimulate the client's cognitive and motor skills, and encourage the client to participate in their own care. This can improve the client's mood and behavior, and foster a positive relationship between the client and the caregiver.
Choice C reason: This method is not appropriate because it can cause emotional and psychological harm to the client. It can make the client feel disrespected, humiliated, or threatened. It can also increase the client's anxiety, agitation, or resistance. This can worsen the client's behavior and damage the trust between the client and the caregiver.
Choice D reason: This method is not appropriate because it can cause physical and psychological harm to the client. It can injure the client's mouth, trigger a gag reflex, or cause choking. It can also make the client feel ignored, neglected, or devalued. This can worsen the client's behavior and damage the trust between the client and the caregiver.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D"]
Explanation
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.
Correct Answer is ["A","B","C"]
Explanation
Choice A reason: This is a correct answer because heart failure is a condition in which the heart cannot pump enough blood to meet the body's needs. This can cause fluid retention and congestion in the lungs, kidneys, and other organs. Heart failure can also affect the thirst mechanism and the secretion of antidiuretic hormone, which can lead to reduced fluid intake and increased fluid loss. Therefore, heart failure can increase the risk of dehydration in older clients.
Choice B reason: This is a correct answer because nonfunctional impairments are limitations in the ability to perform activities of daily living, such as bathing, dressing, or toileting. Nonfunctional impairments can be caused by various factors, such as cognitive decline, mobility problems, or sensory loss. Nonfunctional impairments can affect the access to fluids, the awareness of thirst, or the ability to swallow. Therefore, nonfunctional impairments can increase the risk of dehydration in older clients.
Choice C reason: This is a correct answer because longitudinal furrows on the tongue are signs of dehydration in older clients. The tongue is a mucous membrane that can reflect the hydration status of the body. Dehydration can cause the tongue to lose its moisture and elasticity, and develop cracks or fissures along its length. Therefore, longitudinal furrows on the tongue can indicate dehydration in older clients.
Choice D reason: This is an incorrect answer because hypertension is not an issue that might put your client at risk for dehydration, but rather a complication of dehydration. Hypertension is the elevation of the blood pressure above the normal range, which can damage the blood vessels and increase the risk of cardiovascular disease. Hypertension can be caused by various factors, such as aging, obesity, smoking, stress, or kidney disease. Dehydration can also cause hypertension, as the loss of fluid can reduce the blood volume and increase the blood viscosity and concentration of sodium. Therefore, hypertension is not a risk factor for dehydration, but a consequence of dehydration.
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