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 D
Explanation
Rationale:
A. Gown: The gown should be removed after the gloves because it may be contaminated but has less direct contact with infectious material. Removing it after gloves helps reduce the risk of spreading pathogens from the hands to the clothing or environment.
B. Mask: The mask is usually removed last to prevent inhalation of airborne or droplet contaminants during PPE removal. Premature removal may expose the nurse to infectious particles still present in the surrounding air.
C. Eyewear: Goggles or face shields should be removed after gloves to avoid contamination of the face during removal. Touching the eyewear with potentially contaminated gloves could transfer pathogens close to the eyes or face.
D. Gloves: Gloves are the most contaminated PPE item due to direct patient contact and should be removed first. This limits the risk of transferring pathogens from the gloves to other PPE or surfaces during the removal process.
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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