A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?

Repeat orientation questions until the client gives a correct response.

Make a personal introduction to the client at each interaction.

Give the client a list of foods to choose from for dinner.

Provide the client with a dark environment for sleeping.

Answer and Explanation

The Correct Answer is B

A.   It is not effective to repeatedly ask orientation questions to a client with dementia. Dementia causes progressive memory loss and cognitive decline, and the client may not be able to provide the correct response even with repeated questioning. This approach can lead to frustration and agitation for the client.
B.   Introducing oneself at each interaction is a good practice because individuals with dementia may have difficulty remembering people or recognizing familiar faces. It helps establish rapport and reduces confusion or anxiety that may arise from not recognizing caregivers or staff.
C.   Providing choices can help empower the client and maintain some level of independence in decision- making. However, it's important to keep the choices limited and clear, as too many options can overwhelm and confuse a person with dementia. Additionally, offering familiar and preferred foods can enhance the client's comfort and enjoyment of meals.
D.   Providing a dark environment for sleeping may not be appropriate for all clients with dementia. Some individuals may become disoriented or agitated in complete darkness. It's generally recommended to provide a quiet and calm environment with subdued lighting during nighttime hours to support restful sleep.

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Correct Answer is D

Explanation

A. Bradycardia (slow heart rate) is not typically associated with alcohol withdrawal. Instead, tachycardia (rapid heart rate) is more commonly observed due to the stimulant effects of alcohol withdrawal on the autonomic nervous system.
B. Drowsiness is not a common symptom of alcohol withdrawal. Instead, individuals may experience insomnia or disturbed sleep patterns as part of withdrawal symptoms.
C. Double vision (diplopia) is not a typical finding in alcohol withdrawal.
D. When a person stops or significantly decreases their alcohol intake after long-term use, the body can react with symptoms like increased blood pressure.

A. Verbally de-escalate the client. B. Obtain a prescription for haloperidol. C. Place the client in restraints. D. Take the client to the seclusion room.

Correct Answer is A

Explanation

A. Verbal de-escalation involves using calm, non-confrontational communication techniques to help calm the client. This can include speaking softly, using non-threatening body language, and actively listening to the client's concerns. It is the first-line intervention for managing escalating behavior because it aims to reduce agitation without the use of physical or chemical restraints.
B. Haloperidol is an antipsychotic medication that may be prescribed for acute agitation and aggression in some situations. However, obtaining a prescription requires provider authorization and should not be the first intervention unless the client's agitation poses an immediate threat to safety and verbal de- escalation has been ineffective. It is typically used when other interventions have not successfully managed agitation.

C. Physical restraints should only be used as a last resort and in accordance with institutional policies and legal guidelines. Restraints are intended to prevent harm to the client or others when all other methods of de-escalation have failed and there is an imminent risk of harm. Placing a client in restraints without attempting verbal de-escalation first can escalate the situation further.
D. Seclusion is also a restrictive intervention that should be used judiciously and only when necessary to protect the client or others from harm. It involves placing the client in a designated, secure area where they can be monitored closely. Similar to physical restraints, seclusion should be considered only after attempts at verbal de-escalation have been unsuccessful and there is a clear risk of harm.

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A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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