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 B

Explanation

Choice A reason: Delaying ambulation until the next day is not an appropriate intervention, as it can cause stiffness, muscle weakness, or joint contractures in the affected knee. The nurse should encourage regular exercise and activity within the client's tolerance level to maintain joint mobility and function.

Choice B reason: Applying moist heat prior to ambulation is an appropriate intervention, as it can reduce pain and inflammation in the affected knee by increasing blood flow and relaxing the muscles and tendons around the joint.

Choice C reason: Using a continuous passive motion machine is not an appropriate intervention for osteoarthritis, as it is mainly used after knee replacement surgery to prevent scar tissue formation and improve range of motion in the new joint.

Choice D reason: Restricting intake of dairy products is not an appropriate intervention for osteoarthritis, as dairy products are good sources of calcium and vitamin D that can support bone health and prevent osteoporosis. The nurse should advise the client to eat a balanced diet that includes fruits, vegetables, whole grains, lean protein, and low-fat dairy products.

A. Recent onset of confusion B. Cool, clammy skin C. Decrease in pulse rate D. Increase in blood pressure

Correct Answer is A

Explanation

Choice A: This is correct. Dehydration can cause electrolyte imbalance and affect the brain function, leading to confusion, dizziness, or lethargy.

Choice B: This is incorrect. Cool, clammy skin is a sign of shock, not dehydration. Dehydration can cause dry, warm skin.

Choice C: This is incorrect. Decrease in pulse rate is a sign of bradycardia, not dehydration. Dehydration can cause increase in pulse rate as the body tries to compensate for the low blood volume.

Choice D: This is incorrect. Increase in blood pressure is a sign of hypertension, not dehydration. Dehydration can cause decrease in blood pressure as the blood volume drops.

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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?

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