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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The first action the nurse should take in this situation is to assess the client's condition for any injuries or signs of distress. Therefore, the nurse should measure the client's vital signs to determine if there are any immediate concerns such as hypotension or tachycardia. After ensuring the client's safety and addressing any immediate needs, the nurse should complete an incident report and document the fall in the client's medical record. The provider may also need to be notified depending on the severity of the fall and any resulting injuries.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries.This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation1.
Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.
Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.
Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.
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