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":"C","dropdown-group-2":"E"}
Explanation
Serotonin syndrome: This is a potentially life-threatening condition caused by an excess of serotonin in the brain. It can occur when there is an increase in the dose of an SSRI or when a new SSRI is introduced, particularly if the client has recently been on another SSRI, as in this case where fluoxetine was switched to paroxetine.
Selective serotonin reuptake inhibitors (SSRIs): Both fluoxetine and paroxetine are SSRIs. The risk of serotonin syndrome increases with changes or increases in the dosage of SSRIs due to the potential for excessive serotonin levels.
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 period12. 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 range34. 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 females56.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 females7.Low hemoglobin and hematocrit levels can indicate anemia, which could explain the client’s reported fatigue and pale mucous membranes87.
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 microliter910. 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 range11. 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 minute412. 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 bleeding13. 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 minute14.A high heart rate, or tachycardia, can be caused by factors such as stress, anxiety, physical exertion, dehydration, and certain medical conditions14. Given the client’s reported symptoms and medical history, this finding warrants immediate follow-up.
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