The client is unconscious and requires total care. Prior to providing oral care; the nurse should assess for which of the following ?

Option 3 : Gag reflex

Explanation

Gag reflex

• It is also known as a pharyngeal reflex.
• It is an involuntary reflex involving bilateral pharyngeal muscle contraction.
• It prevents swallowing by contracting the pharynx.
• Assessing gag reflexes will help the nurse determine whether the patient will be given oral care or not.
• It helps to evaluate the medullary brainstem and plays an important role in the declaration of brain death.

Presence of pain

• It will not be determined because the client is unconscious.
• It will not help to determine whether oral care will be provided or not.

Condition of skin

• It will not help to determine whether oral treatment will be given or not.

Range of motion

• This is not true because oral care is not related to it.
• It helps to determine the movement of joints.