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 C
Explanation
Choice A rationale
Ticks should not be removed by squeezing the body with tweezers, as this can cause the tick to regurgitate its stomach contents into the bloodstream, increasing the risk of infection transmission. The proper technique involves using fine-tipped tweezers to grasp the tick as close to the skin's surface as possible and pulling upward with steady pressure.
Choice B rationale
Testing for Lyme disease is not recommended immediately after a tick bite because the antibodies may not be detectable yet. The incubation period for the bacteria is several weeks. It is recommended to watch for symptoms and seek testing only if the characteristic bull's-eye rash or other symptoms develop, which typically occurs 3 to 30 days post-bite.
Choice C rationale
Using a product with DEET (N,N-diethyl-meta-toluamide) is a highly effective measure for preventing tick bites. DEET acts as a repellent that deters ticks and other insects from landing on the skin or clothing. It is a proven preventative strategy that significantly reduces the risk of contracting Lyme disease when walking in wooded or grassy areas.
Choice D rationale
Symptoms of Lyme disease, such as the characteristic erythema migrans (bull's-eye rash), typically appear within 3 to 30 days after being bitten by an infected tick. They do not appear within 2 days. The incubation period is a crucial factor in monitoring for the disease and seeking timely medical care if symptoms arise. .
Correct Answer is D
Explanation
Choice A rationale
Crusting along the incision line is the result of dried serous fluid and blood, which is a normal part of the wound healing process during the inflammatory phase. This finding alone is not indicative of a surgical site infection, which is characterized by other signs.
Choice B rationale
A temperature of $37.2^\circ C$ ($99^\circ F$) is within the normal range for body temperature ($36.1^\circ C$ to $37.2^\circ C$ or $97^\circ F$ to $99^\circ F$). An elevated temperature, specifically a fever, is a systemic sign of infection. A low-grade fever might be a subtle sign, but this temperature is not high enough.
Choice C rationale
Pink coloration of the incision line is a normal finding in the early stages of wound healing, representing angiogenesis, the formation of new blood vessels. This process is crucial for tissue repair and does not indicate a surgical site infection, which is typically characterized by erythema and warmth.
Choice D rationale
Swelling, or edema, is a classic sign of inflammation and infection. While some minor swelling is normal, swelling that extends significantly beyond the wound margins, such as 3.8 cm (1.5 in), indicates a heightened inflammatory response potentially due to bacterial proliferation and infection. *.
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