A nurse is planning care for an older adult client who has dementia.
Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).
Allow the client to choose among a variety of activities each day.
Give the client one simple direction at a time.
Reinforce orientation to time, place, and person.
Establish eye contact when communicating with the client.
Correct Answer : B,C,D
The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.
These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.
Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.
The nurse should provide a structured and consistent daily routine for the client.
Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.
The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because at 12 weeks of gestation, the uterus is still low in the pelvis and the fetal heart tones are best audible through the fetal back, which is usually located just above the symphysis pubis. The fetal heart rate at this stage is normally between 120 and 180 beats per minute.
Choice B is wrong because measuring the fundal height is not necessary to determine the placement of the ultrasound stethoscope at 12 weeks of gestation. The fundal height is usually measured from 20 weeks of gestation onwards to assess fetal growth and estimate gestational age.
Choice C is wrong because placing the client in a side-lying position prior to assessing the fetal heart rate is not required at 12 weeks of gestation. This position may be helpful later in pregnancy to improve maternal blood flow and oxygen delivery to the fetus, especially if there are signs of fetal distress or hypoxia.
Choice D is wrong because performing Leopold maneuvers prior to auscultating the fetal heart rate is not appropriate at 12 weeks of gestation.
Leopold maneuvers are a series of four steps to palpate the abdomen and determine the fetal position, presentation, lie, and engagement. They are usually performed after 24 weeks of gestation when the fetus is large enough to be felt through the abdominal wall.
Correct Answer is ["B","C","E"]
Explanation
The nurse should include the following statements in the teaching:
- You should eat foods that are low in fat. A low-fat diet can help reduce the amount of digestive enzymes your pancreas releases and prevent further inflammation and pain.
- Notify your provider if you experience vomiting or diarrhea. These symptoms can lead to dehydration and malnutrition, which can worsen your condition and require hospitalization.
- You should eat foods high in protein. Protein can help your body heal and repair damaged tissues. It can also prevent muscle wasting and weight loss, which are common complications of chronic pancreatitis.
Choice A is wrong because caffeine can stimulate the pancreas and increase pain and inflammation. Choice D is wrong because alcohol can damage the pancreas and trigger more attacks. People with chronic pancreatitis should avoid alcohol completely.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today