A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

Place the client's bed at the lowest height.

Request a prescription for a nightly sedative.

Assist the client with toileting at least once every 4 hours.

Turn off all lights in the client's room at night.

Answer and Explanation

The Correct Answer is A

Choice A reason: Placing the client's bed at the lowest height is a safety intervention that minimizes the risk of injury from falls, which is particularly important for clients with dementia who may have impaired mobility or judgment. Lowering the bed height can reduce the severity of an injury if a fall does occur. Additionally, it can facilitate easier access for the client to get in and out of bed with less assistance.

Choice B reason: Requesting a prescription for a nightly sedative is not typically recommended as a first-line intervention for clients with dementia. Sedatives can increase the risk of confusion, falls, and can worsen cognitive impairment in the elderly. Non-pharmacological approaches are preferred for managing sleep disturbances in dementia patients.

Choice C reason: Assisting the client with toileting at least once every 4 hours is an important intervention to maintain hygiene and comfort, as well as to prevent urinary tract infections and skin breakdown. However, the frequency of toileting assistance should be individualized based on the client's needs and level of incontinence.

Choice D reason: Turning off all lights in the client's room at night is not advisable as some clients with dementia may experience increased confusion or agitation in complete darkness. A nightlight or low-level lighting can provide a safer environment and help to orient the client during nighttime hours.

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Correct Answer is C

Explanation

Choice A: Rinse your mouth with hydrogen peroxide

Rinsing the mouth with hydrogen peroxide is not recommended for clients with mucositis. Hydrogen peroxide can be too harsh and may cause further irritation to the already sensitive mucosal lining. It is generally advised to use mild rinses such as saline or baking soda solutions.

Choice B: Brush your teeth for 60 seconds twice daily

While brushing is important, it should be done gently with a soft-bristled toothbrush, and the timing should be based on patient tolerance rather than a strict 60-second rule.

Choice C: Floss your teeth gently following each meal

Gentle flossing helps remove food particles and bacteria, reducing the risk of infection. However, if bleeding occurs, the patient should stop and consult a healthcare provider.

Choice D: Wear your dentures only during meals

Wearing dentures only during meals might be advisable for some clients with mucositis, as wearing them all day could irritate the inflamed oral tissues. However, it’s important for the dentures to fit properly and for the client to have periods of rest without the dentures to allow the oral tissues to heal.

A. "You should limit discussing past events with the client." B. "We will respect what is important to you." C. "We will arrange all burial services." D. "Grieving should not be done in front of the client."

Correct Answer is B

Explanation

Choice A reason: The statement "You should limit discussing past events with the client" does not necessarily incorporate the client's and family's cultural beliefs. Discussing past events can be a part of reminiscence therapy, which can be beneficial for clients with terminal illnesses. It allows them to reflect on their life experiences and can provide a sense of fulfillment or closure.

Choice B reason: Saying "We will respect what is important to you" is a broad and inclusive statement that acknowledges the importance of the client's and family's cultural beliefs. It implies that the care team is willing to listen and adapt the care plan to align with the client's values, which is a fundamental aspect of culturally competent care. This approach can help ensure that the client's end-of-life care is respectful and responsive to their individual needs.

Choice C reason: Offering to "arrange all burial services" may not be appropriate as it assumes that the family requires assistance with this aspect of care without first understanding their specific cultural or religious practices. It is important to have a conversation with the client and family about their preferences and needs regarding end-of-life rituals before making any arrangements.

Choice D reason: The statement "Grieving should not be done in front of the client" may not align with the cultural beliefs of the client and family. Grieving practices vary widely among different cultures, and some may find it important to express grief openly in the presence of the dying person. It is essential to respect and accommodate the family's grieving process.

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