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.).

Allow the client to choose among a variety of activities each day.

Give the client one simple direction at a time.

Reinforce orientation to time, place, and person.

Establish eye contact when communicating with the client.

Refute the client’s delusions using logic.

Answer and Explanation

Correct Answer : B,C,D

The correct answer is choice B, C, and D. The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.

These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.

Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.

The nurse should provide a structured and consistent daily routine for the client.

Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.

The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.

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Correct Answer is D

Explanation

Provide humidification of the room air. This is because humidification can help moisten the oral mucosa and reduce the discomfort of xerostomia. Xerostomia is a condition of dry mouth caused by reduced or absent saliva flow, which can occur after radiation therapy to the head and neck area.

Choice A is wrong because rinsing the mouth with an alcohol-based mouth wash can irritate the oral tissues and worsen xerostomia. Alcohol can also dehydrate the mouth and reduce saliva production.

Choice B is wrong because esophageal speech is a method of voice restoration after laryngectomy, not a treatment for xerostomia.

Esophageal speech involves swallowing air into the esophagus and releasing it to create sound.

It has nothing to do with saliva flow or dry mouth.

Choice C is wrong because saltine crackers are dry and hard to swallow without adequate saliva.

They can also scratch the oral mucosa and cause pain or bleeding. Offering the client saltine crackers between meals can aggravate xerostomia and increase the risk of choking.

Normal ranges for saliva flow vary depending on the method of measurement, but generally, a stimulated saliva flow rate of less than 0.7 mL/min or an unstimulated saliva flow rate of less than 0.1 mL/min is considered indicative of xerostomia.

A. Use gestures to convey meaning. B. Pause in the middle of sentences C. Speak slowly when talking to the interpreter D. Speak directly to the client

Correct Answer is D

Explanation

The correct answer is choice D. Speak directly to the client. This is because the nurse should establish eye contact and rapport with the client, not the interpreter, and show respect for the client’s culture and autonomy. The nurse should also use simple and clear language, avoid jargon and slang, and speak in short sentences.

Choice A is wrong because using gestures to convey meaning can be confusing or offensive to some cultures. The nurse should avoid relying on nonverbal communication and ask the interpreter for clarification if needed.

Choice B is wrong because pausing in the middle of sentences can disrupt the flow of communication and make it harder for the interpreter to translate accurately. The nurse should pause at the end of each complete thought or sentence to allow the interpreter to relay the information.

Choice C is wrong because speaking slowly when talking to the interpreter can imply that the interpreter is incompetent or unintelligent. The nurse should speak at a normal pace and tone, and allow enough time for the interpreter to translate.

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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

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Explanation

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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.).