A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?
"Give the client several choices of foods for meals."
"Avoid making eye contact with the client."
"Increase environmental stimuli”
"Label the door to the bathroom with a symbol."
The Correct Answer is D
Rationale:
A. "Give the client several choices of foods for meals.": Providing multiple options can overwhelm a client with dementia and increase confusion or frustration. It is better to offer one or two simple choices to support decision-making without causing cognitive overload.
B. "Avoid making eye contact with the client.": Avoiding eye contact can appear dismissive or impersonal. Maintaining gentle eye contact helps establish trust, enhances communication, and can be grounding for clients who are cognitively impaired.
C. "Increase environmental stimuli”: A stimulating environment can lead to agitation or disorientation in clients with dementia. These clients benefit from calm, predictable surroundings with reduced noise, clutter, and distractions to support cognitive clarity.
D. "Label the door to the bathroom with a symbol.": Using clear labels or symbols helps orient clients with dementia and reduces confusion. Visual cues support recognition and promote independence in navigating their environment, especially with essential tasks like toileting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Rationale:
A. Request the AP to provide a return demonstration of the task: Having the assistive personnel perform a return demonstration allows the nurse to directly observe their technique, ensuring the AP is competent and following proper procedures to prevent complications such as aspiration or infection.
B. Tell the AP to list the steps of the task: While verbalizing steps shows knowledge, it does not guarantee the AP can safely and effectively perform the feeding. Practical demonstration is necessary for skill verification.
C. Ask the family if the AP performed the task correctly: Family feedback may be subjective and is not a reliable method to assess the AP’s competency. The nurse should perform direct assessment.
D. Instruct the AP to report back once the task is complete: Reporting completion alone does not provide information about the quality or safety of the procedure. Direct observation is required to ensure proper technique.
Correct Answer is B
Explanation
Rationale:
A. The client's next dressing change is scheduled in 4 hr.: This is routine scheduling information that does not require input from the entire interprofessional team. It is more relevant for shift handoff or task tracking than for collaborative care planning.
B. The client has developed difficulty ambulating: New or worsening mobility issues can impact the client’s safety, rehabilitation needs, discharge planning, and therapy referrals. This information is essential for all members of the interprofessional team, including physical therapists and case managers.
C. The client's vital signs are checked every 8 hr.: This detail reflects standard monitoring protocol and does not provide meaningful insight into the client’s current health status or changes that would impact team planning or intervention.
D. The client has state-sponsored health insurance: While insurance type may influence discharge or equipment planning, it is handled by social services or case management. It is not the most relevant information to bring forward in a clinical team meeting.
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