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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 A

Explanation

When assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious, the nurse should prioritize assessing the client's suicide risk. This is because the client's symptoms, particularly feelings of depression and anxiety, can indicate a higher risk for self-harm or suicide. Assessing suicide risk is crucial to ensure the client's safety and provide appropriate interventions if needed.

incorrect:

B. Coping abilities: While assessing coping abilities is important to understand how the client manages stress and emotional challenges, it is secondary to assessing suicide risk. Coping abilities can be explored in subsequent assessments to determine the client's resilience and available resources for support.

C. Psychiatric history: Although understanding the client's psychiatric history is relevant for comprehensive care, it may not be the most immediate concern during the admission process. Assessing suicide risk takes precedence to ensure the client's safety.

D. Support systems: While assessing the client's support systems is valuable for understanding the available network of support, it should not take priority over assessing suicide risk. The client's immediate safety and potential need for intervention require immediate attention.

A. "A psychiatrist determines that the client's behavior is irrational. B. "The client is unable to manage the affairs necessary for daily life." C. "The client's behavior is a threat to self or others. D. "The client has been accused of breaking the law."

Correct Answer is C

Explanation

Involuntary commitment refers to the legal process by which an individual is admitted to a psychiatric facility for treatment against their will. The decision to involuntarily commit someone is typically based on the assessment that their behavior poses a risk of harm to themselves or others. Therefore, it is important for the nurse to inform the client's family that the reason for the involuntary commitment is the client's behavior being a threat to their own safety or the safety of others.

A."A psychiatrist determines that the client's behavior is irrational." This statement is incorrect because irrational behavior alone is not sufficient grounds for involuntary commitment.

Involuntary commitment is typically based on the assessment that the individual's behavior poses a risk of harm to themselves or others, rather than solely on the basis of irrational behavior.

B. "The client is unable to manage the affairs necessary for daily life." While the inability to manage daily affairs may be a factor considered in the overall assessment of a client's condition, it is not the sole criterion for involuntary commitment. Involuntary commitment is primarily focused on the risk of harm posed by the individual's behavior, rather than their ability to manage daily life tasks.

D. "The client has been accused of breaking the law." Accusations of breaking the law are not the basis for involuntary commitment. Involuntary commitment is based on the assessment that the individual's behavior presents a risk of harm to themselves or others. Legal issues are addressed separately through the legal system and are not directly related to the criteria for involuntary commitment.

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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.

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A nurse on an inpatient mental health unit is assisting with the admission of a client who reports feeling depressed, sad, moody, and overly anxious. Which of the following assessments should the nurse make first?

Correct Answer is A

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.