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.

Answer and Explanation

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. *.

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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.

A. Administer the mixture within 5 minutes of preparing it. B. Inject air into the regular insulin vial before injecting air into the NPH vial. C. Withdraw the NPH insulin before the regular insulin. D. Shake both insulin vials for 2 minutes before withdrawing the doses.

Correct Answer is A

Explanation

Choice A rationale

Regular insulin is a rapid-acting insulin, and NPH is an intermediate-acting insulin. When mixed in the same syringe, the regular insulin molecules can bind to the protamine in the NPH suspension. This can alter the absorption profile of the regular insulin, delaying its onset of action. Administering the mixture within 5 minutes prevents this molecular interaction and ensures the regular insulin retains its rapid-acting properties.

Choice B rationale

It is crucial to inject air into the NPH insulin vial first, followed by the regular insulin vial, and then withdraw the regular insulin dose before the NPH. This specific order prevents the NPH from contaminating the regular insulin vial with protamine, which would alter the potency and action profile of the regular insulin for future use. The regular insulin is then drawn up first.

Choice C rationale

The correct procedure is to withdraw the regular insulin before the NPH insulin. The sequence is to inject air into both vials, then draw up the clear, rapid-acting regular insulin first, followed by the cloudy, intermediate-acting NPH insulin. This sequence is essential to prevent contamination of the regular insulin vial with the NPH insulin, which could affect its rapid-acting properties.

Choice D rationale

Shaking insulin vials is generally discouraged as it can lead to the formation of air bubbles, which can result in an inaccurate dose. Instead of shaking, the NPH insulin vial should be gently rolled between the palms of the hands. This action warms the insulin and resuspends the particles uniformly without causing bubbles, ensuring an accurate and consistent dose is administered. .

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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?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is A

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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?