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."

Answer and Explanation

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.

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Correct Answer is D

Explanation

Rationale:

A. Mix the medication in juice prior to administration: Montelukast can be mixed with soft foods like applesauce, but mixing it in juice is not specifically recommended due to potential taste masking and dosing accuracy issues. Instructions should follow the manufacturer’s guidelines.

B. Administer the medication when the toddler has an acute asthma attack: Montelukast is a maintenance medication used to prevent asthma symptoms and is not effective for treating acute asthma attacks. A rescue inhaler like albuterol should be used during acute episodes.

C. Provide an additional dose of the medication prior to physical activity: Montelukast is not typically dosed in response to physical activity. While it can help prevent exercise-induced bronchospasm, it should be taken once daily in the evening, not additionally before exertion.

D. Administer the medication to the toddler each evening: Montelukast is prescribed as a once-daily maintenance therapy and is most effective when given in the evening. This helps maintain consistent blood levels and prevents nighttime asthma symptoms.

A. Pedal pulses B. Heart rate C. Oxygen saturation D. Blood pressure E. Abdominal dressing F. Breath sounds

Correct Answer is ["B","D","E"]

Explanation

Rationale:

• Heart rate of 110/min indicates tachycardia, which can be an early sign of hypovolemia, sepsis, or pain and should be followed up due to the recent report of a "popping" sound and increased drainage.
• Abdominal dressing now has a large amount of serosanguinous drainage, suggesting possible wound dehiscence or evisceration, which is a surgical emergency requiring prompt evaluation.
• Blood pressure of 98/50 mm Hg indicates hypotension, which, along with tachycardia and fever, suggests potential sepsis or internal fluid loss and needs immediate intervention.

• Pedal pulses are 2+, which is within normal limits and unchanged from Day 1, indicating adequate peripheral perfusion at present.
• Oxygen saturation at 95% on room air is within normal limits and not significantly changed from previous levels, requiring no urgent action.
• Breath sounds are still clear and present bilaterally, indicating no respiratory compromise or pulmonary complication at this time.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with the parents of a toddler who has a new diagnosis of asthma and a prescription for montelukast. Which of the following instructions should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is assisting with the care of a client Exhibits Select the 3 findings that require immediate follow-up.

Correct Answer is ["B","D","E"]

Explanation

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