A nurse is contributing to the plan of care for a client who was newly admitted and has tuberculosis. Which of the following actions should the nurse recommend Including in the plan of care?

Choice A Reason:

Illusions typically involve misperceptions of sensory stimuli and can occur in various mental health conditions but are not specific to dementia.

Choice B Reason:

Memory loss that disrupts ADLs is correct. Memory loss that disrupts activities of daily living (ADLs) is a common and characteristic finding in individuals with dementia. Dementia is a progressive neurological disorder that affects cognitive function, including memory. As it progresses, individuals with dementia often experience increasing difficulty with memory and daily functioning.

Choice C Reason:

Pressured speech is a symptom often seen in conditions like mania or bipolar disorder but is not typically associated with dementia.

Choice D Reason:

Catatonia is a neuropsychiatric syndrome that can occur in conditions like schizophrenia but is not a common feature of dementia.

Choice A Reason:

Blaming the assistive personnel without additional information or evidence may not be appropriate and should be investigated further.

Choice B Reason:

Mentioning that an incident report has been completed and sent to risk management is important for institutional record-keeping and follow-up but does not provide details about the incident itself.

Choice C Reason:

"Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'." In the documentation of a client fall, it is important to include the client's own account of the incident, as this can provide valuable information about the circumstances surrounding the fall. Including direct quotes or statements from the client helps to accurately capture their perspective and can be useful for assessing the root causes of the fall and developing appropriate interventions to prevent future falls.

Choice D Reason:

Documenting that the client does not appear to have any injuries is relevant but does not provide information about the circumstances of the fall, which is important for a comprehensive understanding of the event.