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 C

Explanation

A. Constipation is a potential side effect of morphine, but it is not the priority concern in this scenario.
B. Euphoria is a potential side effect of morphine but is not as immediately concerning as bradypnea.
C. Correct. Bradypnea (slow breathing) is a potential adverse effect of morphine and can lead to respiratory depression, which is a serious concern.
D. Sedation is an expected side effect of morphine, but the priority concern is the possibility of respiratory depression.

A. Ensure that multiple nurses are present for the physical examination. B. Reassure the child that no one will be told about the abuse. C. Explain to the child what will happen when the abuse is reported. D. Use leading statements to obtain information from the child.

Correct Answer is C

Explanation

A. Incorrect. While it’s important to have support during an examination, having multiple nurses present could be overwhelming for the child and may not be necessary. Instead, it's often best to have a single nurse and possibly a pediatric specialist or social worker present, ensuring the child feels safe and comfortable.
B. Incorrect. Reassuring the child that no one will be told is inappropriate as reporting suspected abuse is required by law.
C. Correct. It helps prepare the child for the next steps in the process and can reduce anxiety. Clear communication fosters trust and helps the child understand the importance of reporting for their safety and well-being.
D. Incorrect. Using leading statements can potentially affect the integrity of the investigation.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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