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A nurse working in a long-term care facility is admitting a client who has dementia.

Exhibits

Which of the following interventions should the nurse include in the plan of care?
Select all that apply.

Obtain client's weight weekly.

Offer the client finger foods for meals.

Speak loudly when addressing the client.

Give long task at a time to the client

Turn the clients TV on at night when they are unable to sleep.

Encourage the client to take deep breaths when feeling agitated.

Assess client's memory every shift.

Answer and Explanation

Correct Answer : A,B,F,G

From the given information, the nurse should include the following interventions in the plan of care for the client with dementia:
●   Obtain client's weight weekly: Regular weight monitoring helps assess the client's nutritional status and detect any significant changes that may require intervention.
●   Offer the client finger foods for meals: Finger foods can be easier for the client to handle and consume independently, promoting independence and self-feeding.
●   Encourage the client to take deep breaths when feeling agitated: Deep breathing exercises can help the client manage their agitation and promote relaxation.
●   Assess client's memory every shift: Regular assessment of the client's memory allows for monitoring any changes or decline, which helps in planning appropriate interventions and providing necessary support.
The following interventions should be avoided:

●   Speak loudly when addressing the client: Speaking loudly may cause confusion or agitation in the client. Instead, it is recommended to use a calm and reassuring tone of voice.
●   Give long tasks at a time to the client: Clients with dementia often have difficulty with concentration and memory. Providing long tasks may overwhelm them and contribute to their frustration. Breaking tasks into smaller, manageable steps is more appropriate.

●   Turn the client's TV on at night when they are unable to sleep: It is generally recommended to create a quiet and calming environment for sleep. The TV may interfere with the client's sleep and contribute to increased agitation or confusion.

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Correct Answer is B

Explanation

Determining if the client has thoughts of self-harm: This is the priority action for the nurse in this situation. Assessing the client's risk of self-harm or suicide is crucial to determine the level of immediate intervention required. It helps identify the severity of the crisis and enables the nurse to implement appropriate measures to ensure the client's safety.

In the context of a client with generalized anxiety disorder who is exhibiting signs of distress and seeking to be taken care of, it is essential to assess for suicidal ideation or intent. Clients with mental health disorders, especially when experiencing high levels of stress, may be at an increased risk of self-harm or suicide. Therefore, it is vital for the nurse to prioritize the assessment of the client's safety and risk of self-harm in order to provide appropriate care and interventions.

Incorrect:

A- Asking the client to identify the cause of the crisis: While it is important to gather information about the cause of the crisis to understand the client's situation, it is not the nurse's priority at this moment. Assessing the client's safety and immediate risk of self-harm takes precedence.

C- Identifying if friends or family are available to help: While social support from friends and family can be valuable in managing a crisis, it is not the nurse's priority in this situation. The immediate concern is to assess the client's safety and risk of self-harm.

D-Identifying the client's coping skills: Assessing the client's coping skills is an important aspect of the overall assessment process, but it is not the priority at this moment. The nurse needs to first ensure the client's safety and address any immediate risks.

A. Denial B. Splitting C. Repression D. Sublimation

Correct Answer is C

Explanation

Repression is a defense mechanism that involves pushing distressing or anxiety-provoking thoughts, memories, or impulses into the unconscious mind. By repressing these thoughts, the individual can avoid dealing with the associated anxiety or discomfort. In the given scenario, the client escapes from anxiety-causing thoughts by ignoring their existence, which aligns with the concept of repression.

Denial, another defense mechanism, involves refusing to acknowledge the existence of a distressing reality or truth. However, in this case, the client is not denying the existence of the thoughts but rather ignoring or avoiding them.

Splitting is a defense mechanism characterized by the inability to integrate positive and negative qualities of oneself or others into a cohesive whole. It is not applicable in this situation.

Sublimation is a defense mechanism in which individuals redirect their unacceptable impulses into more socially acceptable outlets. It involves channeling potentially harmful or unacceptable desires into constructive behaviors. The given scenario does not reflect sublimation as the individual is not redirecting their anxiety into a productive activity or behavior.

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A nurse working in a long-term care facility is admitting a client who has dementia. Exhibits 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

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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A nurse working in a long-term care facility is admitting a client who has dementia.

Exhibits

Which of the following interventions should the nurse include in the plan of care?
Select all that apply.