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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Displacement is a defense mechanism where a person redirects their emotional impulses, such as anger or frustration, from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting their anger towards the nurse when medication changes are prescribed by the provider. The nurse becomes the target of the client's anger, even though the nurse is not directly responsible for the medication changes.
Conversion is a defense mechanism where psychological distress is expressed as physical symptoms or ailments.
Splitting is a defense mechanism where a person sees things as either all good or all bad, with no middle ground or ambivalence.
Sublimation is a defense mechanism where unacceptable impulses or behaviors are channeled into socially acceptable and constructive outlets.
Correct Answer is B
Explanation
This is done by aspirating a small amount of stomach contents and testing the pH using pH paper or a pH indicator strip. The pH of stomach contents is typically acidic (pH less than 5), indicating proper placement in the stomach.
Injecting air and listening for bubbling is not a reliable method to verify tube placement, as it can lead to complications such as pneumothorax.
Measuring gastric residual is done to assess the amount of gastric contents remaining in the stomach, but it does not confirm tube placement.
Adding food coloring to the formula is not a standard practice and does not provide reliable confirmation of tube placement.
X-ray is the gold standard method to confirm tube placement but is not typically done before every intermittent feeding unless there are concerns about tube placement
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