A nurse is caring for a client who has dementia and is experiencing confusion. Which of the following actions should the nurse take?

Discourage reminiscing about the past to minimize feelings of confusion.

Ask open-ended questions that encourage the client to express their feelings.

Use holiday decorations to provide orientation to the time of the year.

Encourage multiple family members to visit the client at the same time.

Answer and Explanation

The Correct Answer is C

Choice A reason: Discouraging reminiscing about the past is not a helpful strategy for a client who has dementia and confusion. Reminiscing can stimulate memory, enhance mood, and promote social interaction.

Choice B reason: Asking open-ended questions that encourage the client to express their feelings is not appropriate for a client who has dementia and confusion. Open-ended questions can increase frustration and anxiety for the client who may have difficulty finding words or recalling events. The nurse should use simple, direct, and closed-ended questions instead.

Choice C reason: Using holiday decorations to provide orientation to the time of the year is a beneficial action for a client who has dementia and confusion. Holiday decorations can help the client recognize familiar cues and reduce disorientation.

Choice D reason: Encouraging multiple family members to visit the client at the same time is not advisable for a client who has dementia and confusion. Multiple visitors can overwhelm and agitate the client who may have trouble recognizing faces or voices. The nurse should limit the number of visitors and ensure they are calm and supportive.

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Correct Answer is C

Explanation

Choice a is not correct because providing an alcohol-based mouthwash is an action that the nurse should avoid when caring for a client who has stomatitis. Alcohol can dry and irritate the oral mucosa and worsen the condition.

Choice b is not correct because minimizing the use of gravies and sauces is not an action that the nurse should take to help manage stomatitis. Gravies and sauces can help moisten dry foods and make them easier to swallow for a client who has stomatitis.

Choice d is not correct because discouraging drinking with a straw is not an action that the nurse should take to help manage stomatitis. Drinking with a straw can help prevent contact between fluids and sore areas of the mouth and reduce pain for a client who has stomatitis.

A. Discard soiled wound care supplies in a trash receptacle outside the client's room. B. Administer antibiotic therapy before culturing the client's wound. C. Instruct visitors to perform hand hygiene for 15 seconds after leaving the client's room. D. Place the client in a private room with a private bathroom.

Correct Answer is D

Explanation

Choice A reason: Discarding soiled wound care supplies in a trash receptacle outside the client's room is not an appropriate action. The nurse should dispose of contaminated materials in a biohazard container inside the client's room to prevent the spread of infection.

Choice B reason: Administering antibiotic therapy before culturing the client's wound is not an appropriate action. The nurse should obtain a wound culture before starting antibiotic therapy to ensure accurate results and avoid altering the microorganisms present in the wound.

Choice C reason: Instructing visitors to perform hand hygiene for 15 seconds after leaving the client's room is not an appropriate action. The nurse should instruct visitors to perform hand hygiene for at least 20 seconds before and after entering the client's room to reduce the risk of transmitting infection.

Choice D reason: Placing the client in a private room with a private bathroom is an appropriate action. The nurse should implement contact precautions for a client who has an infectious wound with foul-smelling drainage to prevent cross-contamination and protect other clients and staff from exposure.

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A nurse is caring for a client who has dementia and is experiencing confusion. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving treatment for cancer and is experiencing stomatitis. Which of the following actions should the nurse take to help manage the condition?

Correct Answer is C

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A nurse is contributing to the plan of care for a client who has developed an infectious wound with foul-smelling drainage. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

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