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 A

Explanation

The correct answer is choice A. Limit oral feedings to 30 min in length.

This is because infants with heart failure have difficulty feeding and may become exhausted or dyspneic during prolonged feedings. By limiting the feeding time, the nurse can reduce the energy expenditure and caloric needs of the infant.

Choice B is wrong because weighing the infant every other day is not enough to monitor the fluid status and nutritional intake of the infant. The nurse should weigh the infant daily at the same time using the same scale.

Choice C is wrong because placing the infant in the prone position can compromise the respiratory function and increase the risk of sudden infant death syndrome (SIDS). The nurse should place the infant in a semi-Fowler’s position to facilitate breathing and decrease venous return.

Choice D is wrong because checking the infant’s oxygen saturation every 6 hr is not frequent enough to detect hypoxia or cyanosis. The nurse should monitor the oxygen saturation continuously or at least every 2 hr.

A. Increased Hct. B. Decreased Hgb C. Increased platelets D. Decreased WBC count

Correct Answer is A

Explanation

Answer and explanation.

The correct answer is choice A. Increased Hct.

Hct stands for hematocrit, which is the percentage of red blood cells (RBCs) in the blood.

A client who received 2 units of packed RBCs should have an increased Hct because they have more RBCs in their blood volume. The normal range for Hct is 38% to 50% for males and 36% to 44% for females.

Choice B is wrong because decreased Hgb means decreased hemoglobin, which is the protein that carries oxygen in the RBCs.

A client who received 2 units of packed RBCs should have an increased Hgb because they have more hemoglobin in their blood. The normal range for Hgb is 13.5 to 17.5 g/dL for males and 12 to 15.5 g/dL for females.

Choice C is wrong because increased platelets means increased thrombocytes, which are the cells that help with blood clotting.

A client who received 2 units of packed RBCs should not have an increased platelet count because they did not receive platelets in the transfusion. The normal range for platelets is 150,000 to 400,000/mm^3.

Choice D is wrong because decreased WBC count means decreased leukocytes, which are the cells that fight infection and inflammation.

A client who received 2 units of packed RBCs should not have a decreased WBC count because they did not receive WBCs in the transfusion. The normal range for WBC count is 4,500 to 11,000/mm^3.

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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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Correct Answer is A

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.).