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 {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

Upper gastrointestinal (GI) endoscopy: This procedure is often indicated for patients presenting with symptoms suggestive of gastrointestinal bleeding, such as dark, tarry stools (melena), which can indicate bleeding in the upper GI tract.

Dark tarry stool: This finding suggests the presence of digested blood, which typically originates from the upper GI tract. This symptom, along with a history of abdominal pain that worsens after eating, indicates a potential peptic ulcer or other upper GI pathology.

A. Current medications B. Temperature C. Hemoglobin and hematocrit D. WBC count E. Blood pressure F. Respiratory rate G. Stool results H. Heart rate

Correct Answer is ["A","C","E","G","H"]

Explanation

The correct answer is:Choices c, e, g, h, and a.

Choice A rationale (Current medications): The client is taking Ibuprofen 800 mg three times daily as needed for arthritis pain.Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can cause gastrointestinal irritation, ulcers, and bleeding, especially when used at high doses or for a prolonged period 1 2. Given the client’s symptoms of abdominal pain and a history of dark, tarry stool, the medication could be contributing to these symptoms and warrants further investigation.

Choice B rationale (Temperature): The client’s temperature is 37.5° C (99.5° F), which is within the normal range 3 4. Therefore, it does not require immediate follow-up.

Choice C rationale (Hemoglobin and hematocrit): The client’s hemoglobin level is 9.1 g/dL, which is lower than the normal range of about 13.0 to 17.5 g/dL for adult males and 12.0 to 15.5 g/dL for adult females 5 6.The client’s hematocrit is 27%, which is also lower than the normal range of about 38.3% to 48.6% for adult males and 35.5% to 44.9% for adult females 7.Low hemoglobin and hematocrit levels can indicate anemia, which could explain the client’s reported fatigue and pale mucous membranes 8 7.

Choice D rationale (WBC count): The client’s WBC count is 6,700/mm3, which falls within the normal range of about 4,500 to 11,000 WBCs per microliter 9 10. Therefore, it does not require immediate follow-up.

Choice E rationale (Blood pressure): The client’s blood pressure is 90/50 mm Hg, which is lower than the normal range 11. Low blood pressure can cause symptoms such as dizziness, fainting, or blurred vision and requires immediate follow-up.

Choice F rationale (Respiratory rate): The client’s respiratory rate is 18 breaths per minute, which is within the normal range for adults of about 12 to 20 breaths per minute 4 12. Therefore, it does not require immediate follow-up.

Choice G rationale (Stool results): The client’s stool tested positive for blood (Hemoccult positive), which could indicate gastrointestinal bleeding 13. This finding, combined with the client’s reported abdominal pain and history of dark, tarry stool, requires immediate follow-up.

Choice H rationale (Heart rate): The client’s heart rate is 118 beats per minute, which is higher than the normal range for adults of about 60 to 100 beats per minute 14.A high heart rate, or tachycardia, can be caused by factors such as stress, anxiety, physical exertion, dehydration, and certain medical conditions 14. Given the client’s reported symptoms and medical history, this finding warrants immediate follow-up.

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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 is caring for a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require an dropdown as evidenced by the client's dropdown.

Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"E"}

Explanation

A nurse is caring for a client who is admitted to the medical-surgical unit. Exhibits The nurse reviews the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","C","E","G","H"]

Explanation

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