A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take?

Provide the client with an electric toothbrush.

Give the client an alcohol-based mouth wash.

Give the client lemon-glycerin mouth swabs.

Provide the client with a spool of dental floss.

Answer and Explanation

The Correct Answer is A

A. Provide the client with an electric toothbrush: An electric toothbrush is an appropriate option for a client with impaired upper extremity strength. It requires less physical effort to use compared to a manual toothbrush, making it easier for the client to maintain oral hygiene effectively. The powered brushing action can help ensure more thorough cleaning of the teeth and gums.

B. Give the client an alcohol-based mouth wash: Alcohol-based mouthwashes can be irritating to the oral mucosa, especially in clients who may have dry mouth or other oral health issues. Instead, a non-alcoholic mouthwash or rinse should be considered to promote comfort and effective oral care.

C. Give the client lemon-glycerin mouth swabs: Lemon-glycerin swabs are not recommended for oral care, as they can be irritating and may cause dryness in the mouth. Additionally, lemon can be acidic and potentially harm the enamel of the teeth. It is better to use products designed for sensitive oral care.

D. Provide the client with a spool of dental floss: While dental floss is important for maintaining oral hygiene, using it requires manual dexterity and strength that may be difficult for a client with impaired upper extremity strength. Instead, alternatives such as floss holders or interdental brushes could be suggested, but the initial focus should be on ensuring the client can effectively brush their teeth.

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Correct Answer is A

Explanation

A. Middle-aged man experiencing the acute phase of myocardial infarction (MI): During the acute phase of an MI, the patient may be experiencing significant physical and emotional stress. Touch may be perceived as intrusive or overwhelming, particularly if the patient is in pain or experiencing anxiety. It's important for the nurse to use caution with touch in this situation, prioritizing verbal communication and ensuring the patient's comfort.

B. Older adult with a history of dementia admitted for dehydration: Touch can often be comforting for individuals with dementia, as it may help to reduce anxiety and provide reassurance. In this case, touch may be beneficial as long as the nurse assesses the individual’s response to touch and proceeds accordingly.

C. Young adult in the rehabilitative phase after arthroscopic surgery: This patient may appreciate touch as a form of encouragement or support during rehabilitation. Unless there are specific contraindications, touch is generally acceptable in this context.

D. Middle-aged woman just diagnosed with terminal lung cancer: While this patient may benefit from touch as a source of comfort and support, the nurse should be sensitive to the patient's emotional state. However, compared to the patient in acute MI, the nurse is less likely to need to use touch cautiously in this situation.

A. Encouraging the client to consume a high-protein diet B. Placing the client in a room with positive-pressure airflow C. Changing the client's bed linens each day D. Performing hand hygiene before, during, and after direct contact with the client

Correct Answer is D

Explanation

A. Encouraging the client to consume a high-protein diet: While a high-protein diet can support the client's immune system and promote healing, it does not directly prevent the transmission of infection. Nutritional support is important for recovery, but it is not a primary strategy for infection control.

B. Placing the client in a room with positive-pressure airflow: Positive-pressure airflow is typically used in rooms for immunocompromised patients to prevent exposure to airborne pathogens, not for clients with infections. Infected patients generally require isolation precautions, which may include negative-pressure rooms, especially for airborne or droplet precautions.

C. Changing the client's bed linens each day: Although maintaining clean linens is important for general hygiene and comfort, simply changing bed linens does not significantly prevent the transmission of infection. Effective infection control measures focus more on direct contact precautions and environmental cleanliness rather than the frequency of linen changes alone.

D. Performing hand hygiene before, during, and after direct contact with the client: Hand hygiene is one of the most effective strategies to prevent the transmission of infections in healthcare settings. Proper handwashing or use of alcohol-based hand rubs significantly reduces the risk of spreading pathogens and protects both the patient and healthcare providers from infections. This strategy is essential in breaking the chain of infection.

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A nurse is providing oral care for a client who had has impaired upper extremity strength. Which of the following actions should the nurse take?

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