An 80-year-old male client is brought to the emergency room by his son with a preliminary diagnosis of dehydration. The client is agitated
When the nurse asks the client to open his mouth for an oral exam, the client yells, "You don't need to look in my mouth to see what is wrong with me!" The nurse's best rationale for looking in his mouth is: 1. That a complete physical exam must be performed.
2. To assess for poorly-fitting dentures.
3. To assess for oral lesions.
4. To assess mucous membranes.
4
Rationale 1: A complete physical exam must be performed. The completion of a physical examination is needed during the admission process, but it is not the most important reason for the oral examination for this client.
Rationale 2: To assess for poorly-fitting dentures. The client's poor nutritional status may be the result of poorly fitting dentures. This will need to be determined, but it is not the most important reason for completing this portion of the assessment.
Rationale 3: To assess oral lesions. The presence of oral lesions may impact the ability of the client to have adequate nutritional intake. The assessment for the presence of the lesions important but not as important as the determination of the presence and degree of dehydration.
Rationale 4: To assess mucus membranes. The condition of the mucous membranes is the most important rationale for the assessment of the oral cavity. The determination of the presence and degree of dehydration is key in beginning the client's treatment.
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