The patient has a risk for skin impairment and has a 15 on the Braden Scale upon admission. The nurse has implemented interventions. Upon reassessment, which Braden score will be the best sign that the risk for skin breakdown is removed?

A. Keep communication simple and concrete: Using simple, straightforward language helps clients who are cognitively impaired to better understand the information being conveyed. Concrete language minimizes confusion and makes it easier for the client to process and respond to what is being said, promoting effective communication.

B. Focus on the client's family: While involving the client's family can be important for support and understanding, the primary focus should be on the client themselves. Communication techniques should prioritize addressing the needs and comprehension of the cognitively impaired client directly.

C. Use open-ended questions: Open-ended questions may be challenging for cognitively impaired clients, as they require more complex processing and can lead to confusion. It is often more effective to use closed questions that allow for simple yes or no responses, making it easier for the client to engage in the conversation.

D. Demonstrate or pantomime ideas: While demonstration can be helpful, it should complement verbal communication rather than replace it. For cognitively impaired clients, combining simple verbal instructions with visual cues or demonstrations can enhance understanding but should not be the sole technique used. It’s important to assess the individual client's abilities and preferences when employing this method.

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.