A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss.

Which of the following strategies should the nurse include in the plan?

Maintain low-level lights in common areas.

Give the client several meal options at lunchtime.

Confront the client regarding inappropriate behavior.

Use symbols in the communal room signage.

Answer and Explanation

The Correct Answer is D

A. Maintain low-level lights in common areas. Low-level lighting can increase confusion and the risk of falls, especially for clients with memory loss. It is important to have adequate lighting to promote a safe environment and help with orientation. Well-lit areas can reduce disorientation and anxiety in clients who are confused or have memory issues.

B. Give the client several meal options at lunchtime. For clients with memory loss and confusion, it is better to provide simple choices or pre-selected meals to reduce decision-making stress and confusion.

C. Confront the client regarding inappropriate behavior. Confronting a client with memory loss or confusion about inappropriate behavior can increase agitation, anxiety, and defensive reactions.

D. Use symbols in the communal room signage. Symbols and pictures can help clients with memory loss navigate their environment more easily because they may have difficulty reading or comprehending written language. Visual cues such as symbols in signage can improve orientation and independence, helping the client feel more comfortable in their surroundings.

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Correct Answer is A

Explanation

Clients in the manic phase often exhibit inflated self-esteem, a sense of superiority, and grandiose thinking. They may have unrealistic beliefs about their abilities, accomplishments, or importance.

Hypersomnia, or excessive sleepiness, is not typically associated with the manic phase of bipolar disorder. Instead, individuals in the manic phase often experience a decreased need for sleep and may go for long periods with little or no sleep.

Blunted affect refers to a lack of emotional expression or reduced intensity of emotional responses. It is more commonly associated with depressive episodes of bipolar disorder rather than the manic phase.

Slurred speech is not a typical finding in the manic phase of bipolar disorder. However, individuals in the manic phase may exhibit rapid or pressured speech, talking excessively, rapidly switching topics, or having difficulty keeping up with their own thoughts.

A. Select the central tip of a finger. B. Wear sterile gloves C. Test the first drop of blood that forms after the puncture D. Keep the finger in a dependent position

Correct Answer is D

Explanation

a.This is not recommended. The central tip of the finger is more sensitive and has more nerve endings, which can cause more pain. The recommended site for blood glucose testing is the side of the fingertip, as it is less sensitive and provides an adequate blood sample.

b. While it is not necessary to wear sterile gloves for routine capillary blood glucose monitoring, it is important to ensure that the nurse's hands are clean. Wearing clean gloves helps maintain infection control practices.

c. After puncturing the selected site, the nurse should gently squeeze the finger to create a small drop of blood. The first drop of blood should be wiped away, and subsequent drops should be used for the glucose test. This ensures that the sample is fresh and not contaminated with tissue fluid.

d.Keeping the finger in a dependent position (hanging down) helps improve blood flow to the fingertip, making it easier to obtain a sufficient blood sample. This can help ensure an accurate glucose reading.

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A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

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A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss.

Which of the following strategies should the nurse include in the plan?