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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

The correct answer is:

Choice C: Determine the medical needs of incoming clients through the emergency department.

Here's a breakdown of the rationale for each choice:

Choice A rationale: While calling in additional staff might be helpful in the long run, during the initial surge of patients in a mass casualty event, the Emergency Department (ED) will be the primary area receiving and triaging patients. The medical-surgical unit will likely receive overflow patients after initial stabilization in the ED.

Choice B rationale: This is not a primary responsibility for a nurse on a medical-surgical unit during a mass casualty event. Communication with the media is usually handled by designated public relations personnel.

Choice C rationale: This is the most crucial action for a nurse in this situation. Triaging patients based on the severity of their injuries and prioritizing care is essential in a mass casualty scenario. Nurses will be instrumental in assessing incoming patients relayed from the ED to determine their medical needs and allocate resources accordingly.

Choice D rationale: Discharging patients is not a priority during the initial influx of casualties. The focus is on receiving, stabilizing, and treating the most critically injured patients. Discharges would likely happen after the initial surge subsides.

A. Measure gastric residual volumes every 4 hr. B. Advance the rate of the feeding every 2 hr. C. Maintain the head of the bed at a 20° angle. D. Flush the NG tube with 30 mL 0.9% sodium chloride before and after medication.

Correct Answer is A

Explanation

This is because continuous enteral feedings through an NG tube can increase the risk of aspiration, which is the inhalation of food or fluids into the lungs. Measuring gastric residual volumes (GRV) can help monitor the tolerance and absorption of the feedings and prevent overfeeding. GRV is the amount of fluid aspirated from the stomach via an enteral tube to check for gastric emptying. The normal range of GRV is less than 200 ml.

Choice B is wrong because advancing the rate of the feeding every 2 hr can lead to overfeeding, abdominal distension, nausea, vomiting and diarrhea.

The rate of the feeding should be adjusted according to the client’s nutritional needs and tolerance.

Choice C is wrong because maintaining the head of the bed at a 20° angle is not enough to prevent aspiration. The head of the bed should be elevated at least 30° to 45° during and for at least one hour after feeding.

Choice D is wrong because flushing the NG tube with 30 mL 0.9% sodium chloride before and after medication is not related to continuous enteral feedings. This is a practice to prevent clogging of the tube and ensure proper delivery of medication. Flushing the tube with water before and after feeding is also recommended to maintain patency and hydration.

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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.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is planning care for a client who has a prescription for continuous enteral feedings through an NG tube. Which of the following actions should the nurse plan to take?

Correct Answer is A

Explanation

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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.).