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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Pupillary dilation is not a sign of opioid toxicity, but rather of opioid withdrawal or stimulant overdose. Opioid toxicity causes pupillary constriction or miosis.
Choice B reason: Hypotension is a sign of opioid toxicity sign of opioid toxicity, as opioids can depress the central nervous system and reduce cardiac output and peripheral resistance.
Choice C reason: Chest pain is not a sign of opioid toxicity, but rather of cardiac ischemia or infarction, which can be caused by cocaine or other stimulants.
Choice D reason: Diaphoresis is not a sign of opioid toxicity, but rather of opioid withdrawal or hyperthermia, which can be caused by ecstasy or other stimulants.
Correct Answer is B
Explanation
Choice A reason: Passing of flatus is not a reliable indicator of colostomy function, as it can occur even when there is an obstruction or ischemia in the bowel.
Choice B reason: Stoma is pinkish-red is a sign of a healthy and well-perfused colostomy, as it indicates that the blood supply to the bowel segment is adequate and there is no necrosis or infection.
Choice C reason: Tolerating a clear liquid diet is not a specific indicator of colostomy function, as it does not reflect the amount or consistency of the stool output.
Choice D reason: Absent bowel sounds are not a normal finding for a colostomy, as they can indicate a paralytic ileus or a bowel obstruction, which can cause complications such as distension, pain, or perforation.
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