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.)
Reinforce orientation to time, place, and person.
Allow the client to choose among a variety of activities each day.
Give the client one simple direction at a time.
Establish eye contact when communicating with the client.
Refute the client's delusions using logic.
Correct Answer : A,C,D
A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired.
B. Incorrect. While it's important to provide the client with some choices, too many options can be overwhelming and confusing.
C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia.
D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.
E. Incorrect. It's generally not effective to try to refute a client's delusions using logic.
Redirecting or validating their feelings might be more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}
Explanation
Pyrexia, also known as fever, refers to an elevated body temperature that is above the normal range. The normal body temperature is typically around 37°C (98.6°F), and a temperature of 38.4°C (101.1°F) indicates a fever.
Alternative Choices:
1. "tachycardia" due to "heart rate of 92/min"
- Incorrect. Tachycardia refers to an abnormally high heart rate, usually above 100 beats per minute (bpm) in adults. A heart rate of 92/min is within normal limits and does not qualify as tachycardia.
2. "hypertension" due to "blood pressure of 130/78 mm Hg"
- Incorrect. Hypertension is defined as having a blood pressure reading consistently above 140/90 mm Hg. The reading of 130/78 mm Hg falls into the elevated category but does not reach the threshold for hypertension.
3. "respiratory distress" due to "respiratory rate of 18/min"
- Incorrect. A respiratory rate of 18 breaths per minute is considered normal for adults, so this finding does not indicate respiratory distress.
4. "obesity" due to "current BMI of 29.9"
- Partially correct. A BMI of 29.9 places the client in the "overweight" category, just below the threshold for obesity (BMI of 30 or higher). However, the presence of pyrexia is the more immediate clinical concern based on the provided vital signs.
Correct Answer is D
Explanation
A. A butterfly needle is not typically used for accessing implanted ports.
B. An angiocatheter is not typically used for accessing implanted ports.
C. A 25-gauge needle might be too small for accessing an implanted port.
D. Correct. A noncoring needle (Huber needle) is specifically designed for accessing implanted venous access ports to minimize damage to the port septum and prevent leakage.
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