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

The correct answer is choice D. Place a wedge under one of the client’s hips. This is because placing a wedge under one of the hips can help prevent compression of the inferior vena cava by the uterus, which can compromise placental blood flow and cause fetal hypoxia. Placing a wedge under the hip can also help reduce the risk of maternal hypotension, which can also affect fetal oxygenation.

Choice A is wrong because inserting a pillow under the client’s knees can increase the risk of thromboembolism, which is a potential complication of cesarean birth.

Choice B is wrong because positioning the client in reverse Trendelenburg can increase the risk of maternal aspiration, which is another potential complication of cesarean birth.

Choice C is wrong because assisting the client into the lithotomy position can also compress the inferior vena cava and reduce placental blood flow. The lithotomy position is also not necessary for cesarean birth, as the baby is delivered through an incision in the abdomen and uterus.

A. Observe the position of the suspended weight B. Check the client’s pedal pulse on the right leg C. Ask the client to describe her pain D. Remind the client to use the incentive spirometer E. None F. None

Correct Answer is D

Explanation

The correct answer is D. Remind the client to use the incentive spirometer.

Choice A rationale:

Observing the position of the suspended weight is beyond the scope of practice for assistive personnel (AP). This task requires assessment skills to ensure proper alignment and functioning of the traction system, which is the responsibility of the nurse.

Choice B rationale:

Checking the client’s pedal pulse on the right leg involves assessment and clinical judgment to evaluate perfusion and detect potential complications such as impaired circulation. This is not a task that can be delegated to AP.

Choice C rationale:

Asking the client to describe her pain requires assessment and interpretation of subjective data, which falls under the nurse's scope of practice. Pain assessment is a critical nursing function.

Choice D rationale:

Reminding the client to use the incentive spirometer is a non-assessment task that involves reinforcing previously taught instructions. This is appropriate to delegate to assistive personnel, as it does not require clinical judgment.

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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 positioning a client for a cesarean birth. To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is developing a care plan for a client who is in Buck’s traction and is scheduled for surgery for a fractured femur of the right leg. Which of the following interventions should the nurse delegate to an assistive personnel?

Correct Answer is D

Explanation

Choice A rationale:

Choice B rationale:

Choice C rationale:

Choice D rationale:

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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.).