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 C
Explanation
Choice A: This is incorrect. The Sims' position is not used for a colposcopy, which is a procedure that examines the cervix with a magnifying device. The client should be placed in the lithotomy position, which involves lying on the back with the legs spread and supported by stirrups.
Choice B: This is incorrect. The nurse should not insert a tampon following the procedure, as this can introduce bacteria and cause infection. The nurse should advise the client to use sanitary pads instead.
Choice C: This is correct. The nurse should instruct the client to avoid sexual intercourse until the cervix is healed, which can take up to a week. Sexual intercourse can cause bleeding, pain, and infection.
Choice D: This is incorrect. The nurse should not reinforce teaching that the procedure involves dilation of the cervix, as this is not true. A colposcopy does not require dilation of the cervix, unlike some other procedures such as endometrial biopsy or hysteroscopy.
Correct Answer is ["A","C","D"]
Explanation
a) You should shower instead of taking a tub bath. This is correct because showering reduces the risk of infection and promotes wound healing.
b) You may take aspirin for mild pain. This is incorrect because aspirin can increase the risk of bleeding and interfere with clotting. The client should take acetaminophen or another nonsteroidal anti-inflammatory drug (NSAID) for pain relief.
c) You should avoid lifting objects that weigh more than 8 pounds. This is correct because lifting heavy objects can strain the surgical site and cause bleeding or herniation.
d) You might see blood in your urine after coughing. This is correct because coughing can increase the pressure in the bladder and cause blood to leak from the urethra. This is normal and should subside within a few days.
e) You may resume sexual intercourse after 2 weeks. This is incorrect because sexual intercourse can cause trauma to the prostate and urethra and delay healing. The client should wait at least 6 weeks before resuming sexual activity.
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