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 A
Explanation
A. "Tell me what the afterlife means to you." Correct. This response demonstrates active listening and encourages the client to share their beliefs and feelings about the afterlife, providing the client with an opportunity for spiritual expression and understanding.
B. "You should discuss the afterlife with your priest." While discussing spiritual matters with a religious leader can be valuable, this response does not directly address the client's request for
the nurse to discuss the afterlife with them.
C. "Keep praying. A miracle could happen." This response may not fully address the client's need to discuss their beliefs about the afterlife. It focuses on hope but does not actively engage in the client's spiritual conversation.
D. "Maybe your condition will lead you closer to God." While offering comfort, this response may not meet the client's request to discuss the afterlife directly.
Correct Answer is A
Explanation
A. Precontemplation
According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage,
the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are pre contemplation, contemplation, preparation, action and the maintenance stage
B. Preparation INCORRECT
The nurse should identify that preparation is the third stage the client will experience when using the stages of health behavior change. In this stage, the client plans to make minor changes to behavior. However, according to evidence-based practice, another stage occurs prior to the preparation stage.
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