Difficulty: Medium
Average Score: 77%
Simulated
A nurse is caring for a client who has a terminal illness and a family member asks why the clientÔÇÖs mouth is continually open. Which of the following responses should the nurse make?
Correct answer
A
Rationale
The reduced muscle tone relaxed the jaw muscles.' CORRECT. Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth. 'That happens when a person gets close to death.' INCORRECT. This automatic response is nontherapeutic and does not address the family memberÔÇÖs question. 'I can apply a chin strap to help hold the mouth closed.' INCORRECT. Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed.