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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Incorrect. Absence seizures typically do not have an aura. They are characterized by a sudden and brief loss of awareness without warning.

B. Correct. Absence seizures often involve a brief period of staring and decreased responsiveness. They can indeed be mistaken for daydreaming, as they are not as dramatic as other types of seizures.

C. Incorrect. Absence seizures are usually very brief, lasting only a few seconds (often less than 10 seconds), rather than 30 to 60 seconds.

D. Incorrect. Absence seizures have a sudden and abrupt onset, not a gradual one. They occur without warning and without a preceding aura.

A. Client reports lower back pain and pinkish vaginal discharge. B. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds. C. Cervical exam indicates 2 cm, 50% effaced, 0 station. D. CBC and urinalysis collected and sent to lab. E. FHR baseline 145, minimal variability.

Correct Answer is ["A","B","C","E"]

Explanation

Client reports lower back pain and pinkish vaginal discharge.

Explanation: Lower back pain and pinkish discharge can indicate preterm labor, especially given the client’s history of a previous preterm birth.

Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.

Explanation: Frequent and strong contractions suggest that labor may be progressing, which is concerning at 33 weeks gestation and needs close monitoring.

FHR baseline 145, minimal variability.

Explanation: Minimal variability in the fetal heart rate (FHR) can be a sign of fetal distress or a lack of fetal well-being, warranting further evaluation.

Cervical exam indicates 2 cm, 50% effaced, 0 station.

Explanation: Cervical dilation and effacement at 33 weeks gestation indicate that labor is progressing. Given the client's history of preterm birth, this finding is concerning and requires intervention to try to prevent another preterm delivery.

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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.)

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Naxlex Comprehensive Predictor Exams

A school nurse is teaching a parent about absence seizures. Which of the following information should the nurse include?

Correct Answer is B

Explanation

Correct Answer is ["A","B","C","E"]

Explanation

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