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

Answer and Explanation

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

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Correct Answer is B

Explanation

A) Autonomy refers to the right of the client to make their own decisions about their care. In this scenario, the nurse respects the client's decision not to take the pill as it is, but does not stop there.
B) Beneficence is the principle of doing good and acting in the best interest of the client. By offering to break the pill, the nurse is actively seeking a solution to ensure the client receives the necessary medication, which is in the client's best interest.
C) Justice relates to fairness and the equal distribution of resources. While important, it is not the primary principle being demonstrated in this situation.
D) Nonmaleficence means to do no harm. Although breaking the pill could be seen as avoiding harm by preventing the client from choking, it is more about ensuring the client's treatment continues effectively, which aligns more closely with beneficence.

A. "I will be sure to keep the crutch tips dry." B. "I will hold a crutch in each hand when sitting down." C. "I will place my weight on my underarms." D. "I will lead with my right leg when going upstairs."

Correct Answer is A

Explanation

A.Keeping the crutch tips dry is essential to prevent slipping and falling, which can lead to further injury. Moisture on the tips can reduce friction, making the crutches unstable on surfaces.

B.When sitting down, the correct technique involves holding both crutches in one hand and using the other hand to lower yourself safely into the chair. Holding a crutch in each hand can make it difficult to balance and sit down safely.

C.Placing weight on the underarms can cause nerve damage and pain. The correct technique is to place weight on the hands and use the muscles of the arms and shoulders to support the body.

D. When going upstairs with a fractured leg, the proper technique is to lead with the uninjured leg, not the injured one. This ensures stability and reduces the risk of further injury to the fractured leg.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is reinforcing teaching about the use of crutches with a client who has a fractured right tibia and fibula. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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