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. "You can apply counterpressure to your back with each position change.": Counterpressure is commonly used during labor to relieve back pain caused by fetal positioning. It is not relevant for postoperative cesarean pain, which is abdominal.
B. "You should change positions as little as possible.": Limiting movement after surgery can increase the risk of complications such as pneumonia and venous thromboembolism. Frequent, supported movement is encouraged to promote recovery and circulation.
C. "You should use patterned-paced breathing when changing positions.": Patterned-paced breathing is typically used during labor for pain management. While breathing techniques may offer mild comfort, they do not provide adequate support for incisional pain during movement.
D. "You can splint the incision with a pillow when changing positions.": Splinting the incision with a pillow provides support to the abdominal muscles, helping reduce tension and pain during movement. This is a safe and effective nonpharmacological strategy for post-cesarean clients.
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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