A nurse is planning care for an older adult client who has dementia and a nutritional deficit.
Which of the following actions should the nurse plan to take?
Serve the client soup in a mug.
Allow the client to cut up her own food.
Use colorful, patterned dishes to serve the client's meals.
Withhold fluids while the client is eating.
The Correct Answer is A
Choice A rationale
Serving soup in a mug promotes independence and is less likely to spill compared to a bowl, which is beneficial for a client with dementia who may have fine motor skill deficits. This action simplifies the eating process, reducing frustration and increasing the likelihood of successful nutrient intake. This is part of providing a safe and dignified environment for the patient.
Choice B rationale
Allowing a client with dementia to cut their own food can be dangerous due to impaired judgment, cognitive decline, and potential motor skill deficits, which increase the risk of injury. Providing pre-cut food is a safety measure that prevents accidental cuts or choking, ensuring the client's well-being and reducing caregiver burden.
Choice C rationale
Colorful, patterned dishes can cause perceptual distortions and visual confusion for a client with dementia due to changes in depth perception and visual-spatial processing. This can make it difficult for them to distinguish the food from the plate, leading to decreased food intake and increased frustration. It is better to use plain, solid-colored dishes.
Choice D rationale
Withholding fluids while a client is eating increases the risk of dehydration and can make swallowing solid foods more difficult, potentially leading to aspiration. It is important to encourage fluid intake throughout the meal to aid in chewing and swallowing, which supports hydration and nutritional status. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Flumazenil is a competitive antagonist for benzodiazepine receptors in the central nervous system. It works by blocking the effects of benzodiazepines, effectively reversing their sedative and anxiolytic effects. It is a specific antidote for benzodiazepine overdose and is indicated for the reversal of conscious sedation or for managing a benzodiazepine overdose. It should be used with caution due to the risk of seizures in long-term users.
Choice B rationale
Atropine is an anticholinergic medication primarily used to treat bradycardia (slow heart rate) and as an antidote for nerve agent or pesticide poisoning. It acts on muscarinic receptors to block the action of acetylcholine. It does not have any effect on benzodiazepine receptors and is therefore not the appropriate medication for treating benzodiazepine toxicity.
Choice C rationale
Activated charcoal is a general adsorbent used to treat certain oral poisonings and overdoses. It binds to the drug in the gastrointestinal tract, preventing its absorption into the bloodstream. It is only effective if administered early after ingestion of the drug. It is not a specific antidote for benzodiazepine toxicity, but a general measure to prevent absorption. Flumazenil is the specific antidote.
Choice D rationale
Naloxone is a narcotic antagonist that reverses the effects of opioid overdose by competing for the same receptor sites. It is specifically used for opioid toxicity and is ineffective for benzodiazepine overdose. Administering naloxone would not alter the effects of benzodiazepines and would be a completely inappropriate intervention for this type of toxicity.
Correct Answer is D
Explanation
Choice A rationale
Rewrapping the bandage every 8 hours is too infrequent. The residual limb bandage should be checked and rewrapped more frequently to ensure continuous, even compression and to prevent the bandage from slipping, which can cause skin irritation or tourniquet effects. The correct application should be in a figure-eight pattern.
Choice B rationale
A client who has undergone a below-the-knee amputation should be turned more frequently than every 4 hours to prevent pressure ulcers and contractures. Turning every 2 hours is the standard of care for a bedridden client. Prolonged pressure on the surgical site can compromise circulation and healing.
Choice C rationale
A trapeze can be a useful tool for clients with lower limb weakness, but for a client post-amputation, excessive upper body strength exertion with the trapeze can cause a compensatory increase in muscle tone and pressure on the stump, which may compromise healing. The focus is to support the residual limb, not to put strain on it.
Choice D rationale
An air mattress, also known as a low-air-loss mattress, is designed to reduce and redistribute pressure evenly across the body's surface. This is particularly important for a client with an amputation to prevent pressure ulcers, promote circulation, and protect the residual limb's surgical incision from excessive pressure, which aids in healing
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