Examkin

Question

Difficulty: HardBasic Care and Comfort

An older adult client with advanced Parkinson's disease is admitted for the management of severe dysphagia and a new sacral pressure injury. The client is receiving continuous enteral nutrition via a gastrostomy tube. During the shift, the client becomes restless, repeatedly attempts to pull on their medical tubing, and experiences sudden new-onset urinary incontinence. Which basic care and comfort interventions should the nurse include in the client's plan of care? Select all that apply.

  1. Perform oral hygiene every 4 hours using a suction-equipped toothbrush and an alcohol-free moisturizing mouthwash.Answer
  2. Camouflage the gastrostomy tubing beneath loose clothing and provide a textured sensory blanket for the client to manipulate.Answer
  3. C
    Lower the head of the bed to a completely flat position while the continuous feeding infuses to facilitate lateral turning.
  4. D
    Instruct the unlicensed assistive personnel (UAP) to evaluate the stage of the sacral pressure injury during the daily bed bath.
  5. E
    Reassure the family that the client's new-onset continuous urinary incontinence is a standard physiological consequence of advanced age.
  6. F
    Apply soft bilateral wrist restraints immediately to ensure the continuous enteral feeding is not interrupted by the client's restlessness.

Answer

The correct interventions are performing frequent oral hygiene using a suction toothbrush and camouflaging the gastrostomy tubing while providing a sensory distraction blanket.
Clients with dysphagia and enteral tubes require frequent oral hygiene with suction to maintain mucosal comfort and prevent the aspiration of colonized oral flora. Additionally, using sensory distractions and hiding medical tubing promotes comfort and safety by serving as a non-restrictive alternative to physical restraints for restless clients.

Step-by-Step Solution

1
Analyze the client's physiological needs (dysphagia, enteral feeding) and comfort/safety needs (restlessness, pulling lines).
Identified the need for meticulous oral care to prevent aspiration and the need for safe, non-restrictive methods to manage the restlessness.
Basic care mandates proactive prevention of complications (like aspiration pneumonia) and prioritizing the least restrictive environment.
2
Evaluate the proposed positioning and delegation tasks.
Identified that lowering the bed while feeding infuses is dangerous, and delegating assessment to a UAP is outside their scope of practice.
Proper positioning is critical for airway protection, and proper delegation ensures safe care delivery.
3
Assess the approach to the client's new-onset incontinence and agitation.
Recognized that sudden incontinence is abnormal (not a product of aging) and that restraints cannot be used as a first-line intervention.
Distinguishing pathology from normal aging is crucial for prompt treatment, and restraint application has strict regulatory limitations.

Key Concept

Basic care encompasses physiological maintenance (oral hygiene, safe positioning during feeding) and the implementation of non-pharmacological comfort measures to manage agitation without prematurely resorting to physical restraints.
Rate this question

Topics

Basic Care and Comfort

More questions from this topic