How can a nurse promote oral hygiene for a patient who is on a ventilator?

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: 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.

Correct Answer: C

Rationale: Safety is not a physiological need per Maslow it's a higher-tier security need unlike oxygen , food , and rest , which sustain life directly. Physiological needs are biological imperatives; safety involves protection, not survival basics. PSWs must distinguish this to prioritize e.g., feeding a client before securing a rail. Mixing these risks neglecting urgent needs, delaying recovery. This hierarchy guides care sequencing, ensuring foundational health before safety measures, a practical lens for PSWs managing daily client demands effectively.

Correct Answer: C

Rationale: Pain and discomfort are subjective felt and reported by the client unlike skin breakdown , temperature , or pulse , which PSWs observe objectively. Subjective data guides care e.g., adjusting position for pain relying on client input. Misclassifying risks ignoring feelings, delaying relief. PSWs record these to inform teams, ensuring holistic responses, a vital skill distinguishing perception from measurable signs in client assessments.