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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.
Correct Answer is D
Explanation
A. Bone pain: Bone pain is not a characteristic finding of hypomagnesemia. Hypomagnesemia is an electrolyte imbalance, and bone pain is not a typical symptom associated with it.
B. Drowsiness: Drowsiness may occur in hypomagnesemia, but it is not a specific or characteristic sign of this condition. Other electrolyte imbalances and medical conditions can also cause drowsiness.
C. Bowel hypomotility: Hypomagnesemia can cause bowel hypomotility (decreased bowel movements), but it is not the most specific finding associated with this condition.
D. Positive Chvostek's sign: Correct. Hypomagnesemia can lead to neuromuscular irritability, and a positive Chvostek's sign is a clinical manifestation of this condition. A positive Chvostek's sign is elicited by tapping the facial nerve (at the level of the zygomatic arch) and observing a
twitching of the facial muscles, which indicates increased neuromuscular excitability.
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