How can a nurse promote oral care for a patient who is unconscious and intubated?

Correct Answer: D

Rationale: Performing oral care with a soft toothbrush and oral swabs for an unconscious, intubated patient removes plaque and secretions, preventing infections like ventilator-associated pneumonia while protecting delicate tissues. Frequent mouthwash alone doesn't clean mechanically and risks aspiration. Weekly care allows bacterial overgrowth, endangering health. Suctioning without gloves breaches infection control gloves are mandatory. Nurses use these tools gently and regularly, often with suction, to maintain hygiene and comfort, a critical intervention in critical care settings.

Correct Answer: B

Rationale: Providing oral care with a swab and appropriate solutions promotes hygiene for a ventilated patient by removing bacteria and secretions, preventing ventilator-associated pneumonia without risking tube displacement. Avoiding care invites infection tubes don't preclude it when done carefully. Drinking water isn't possible; they're intubated. Limiting to awake times ignores constant need unconscious care is standard. Nurses use chlorhexidine or swabs gently, coordinating with respiratory staff, ensuring oral health and systemic safety in critical care.

Correct Answer: D

Rationale: A soft-bristle toothbrush minimizes gum irritation and damage by cleaning teeth gently, avoiding trauma to sensitive tissues, especially in frail or ill patients. Preventing decay is a benefit, but the focus is gum safety hard bristles harm more. Time-saving isn't its purpose; technique matters over speed. Gum stimulation occurs mildly, but protection trumps it. Nurses choose soft bristles to balance efficacy and gentleness, ensuring oral health without pain or bleeding, a key consideration in patient comfort.

Correct Answer: A

Rationale: Sexual function is not a typical emotional or psychological reaction to illness or disability it's a physiological aspect that might be affected, not a response. Denial (refusing to accept a diagnosis), depression (sadness from loss of ability), and anger (frustration at limitations) are well-documented reactions, per models like Kübler-Ross's stages of grief. Health care aides observe these in clients adjusting to conditions, offering empathy or reporting shifts. Mislabeling function as a reaction could confuse care e.g., addressing libido changes requires different support than handling denial making this distinction key for effective, compassionate responses.

Correct Answer: C

Rationale: The policy and procedure manual provides specific guidance on handling falls e.g., assessing injury, reporting protocols ensuring a standardized, safe response. Following the nurse is reactive, not proactive, and lacks written clarity. Job description outlines roles, not incident steps. MDS tracks status, not emergency actions. Health care aides rely on these manuals for consistent, facility-approved steps, avoiding guesswork e.g., checking vitals, notifying supervisors protecting Mrs. Schmidt and meeting regulatory standards, a critical resource in urgent scenarios.