A nurse is caring for a client who has dementia.
Which of the following actions should the nurse take to promote communication?
Face the client at eye level when communicating.
Offer correction of incorrect client statements.
Reorient the client to date and time with each encounter.
Avoid using gestures when communicating with the client.
The Correct Answer is A
Face the client at eye level when communicating.
This is because eye contact helps to establish rapport and trust with the client who has dementia and shows respect and attention. Facing the client at eye level also reduces distractions and background noise that might interfere with communication.
Choice B is wrong because offering correction of incorrect client statements can increase confusion, frustration, and agitation in the client who has dementia. Instead of correcting the client, the nurse should acknowledge their feelings and try to understand their perspective.
Choice C is wrong because reorienting the client to date and time with each encounter can be stressful and ineffective for the client who has dementia. Reorientation may work in the early stages of dementia, but as the disease progresses, the client may lose their ability to retain new information and may become more disoriented. Instead of reorienting the client, the nurse should use orienting names or labels whenever possible, such as “Your son, Jack” .
Choice D is wrong because avoiding using gestures when communicating with the client who has dementia can limit the nurse’s ability to convey meaning and emotion. Gestures can help to supplement verbal communication and provide cues for the client who has difficulty understanding words. However, the nurse should avoid using gestures that might be misinterpreted or threatening to the client, such as pointing or waving .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This statement indicates that the client has orthopnea, which is a sign of worsening heart failure and fluid overload. The nurse should intervene by assessing the client’s vital signs, oxygen saturation, lung sounds, and edema, and notifying the provider for possible diuretic adjustment.
Choice A is wrong because “I’m urinating in larger amounts.” is an expected outcome of taking furosemide, which is a loop diuretic that increases urine output and reduces fluid retention.
Choice C is wrong because “I suck on hard candy for my dry mouth.” is a harmless way to cope with the side effect of dry mouth caused by furosemide.
Choice D is wrong because “I’ve lost 3 pounds in the last week.” is a positive sign that the client is losing excess fluid and improving their heart failure
condition. A weight loss of 2 to 4 pounds per week is acceptable for clients taking diuretics.
Normal ranges for heart failure clients are:
- Blood pressure: less than 140/90 mmHg
- Heart rate: 60 to 100 beats per minute
- Respiratory rate: 12 to 20 breaths per minute
- Oxygen saturation: greater than 95%
- Weight: stable or decreasing within 2 to 4 pounds per week
Correct Answer is D
Explanation
BMI 32.2.
A high body mass index (BMI) is a major risk factor for type 2 diabetes mellitus, as it indicates overweight or obesity.
Overweight or obesity can cause insulin resistance, which means the body cells do not respond well to insulin and cannot take up glucose from the blood. This leads to high blood sugar levels and diabetes.
Choice A is wrong because history of exercise-induced asthma is not a risk factor for type 2 diabetes mellitus.
Asthma is a respiratory condition that causes inflammation and narrowing of the airways, but it does not affect the metabolism of glucose or insulin.
Choice B is wrong because age 35 years is not a risk factor for type 2 diabetes mellitus.
Although the risk of diabetes increases with age, especially after 45 years, it can also occur in younger people.
Age alone is not enough to cause diabetes.
Choice C is wrong because history of mumps is not a risk factor for type 2 diabetes mellitus.
Mumps is a viral infection that affects the salivary glands, but it does not damage the pancreas or impair insulin production.
Some other risk factors for type 2 diabetes mellitus are family history, race or ethnicity, physical inactivity, prediabetes, gestational diabetes, polycystic ovarian syndrome, and smoking.
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