A nurse working in a long-term care facility is admitting a client who has dementia.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Leaving the child's room exactly as it was before the loss suggests that the client is unable to accept and adapt to the reality of the child's death. This behavior can be considered maladaptive because it hinders the process of mourning and moving forward. It may reflect a difficulty in accepting the loss and adjusting to life without the child.
The other actions mentioned in the options are not necessarily indicative of maladaptive grieving:
B. Visiting the child's grave every week: Visiting the child's grave can be a normal part of the grieving process for some individuals. It provides an opportunity for the client to remember and honor the child's memory.
C. Talking about the child in the past tense: It is common for individuals to talk about a deceased loved one in the past tense. This does not necessarily indicate maladaptive grieving. It is a way of acknowledging the loss and recognizing that the person is no longer physically present.
D. Volunteering at a local children's hospital: Engaging in volunteer work can be a positive coping mechanism for individuals who have experienced a loss. It allows them to find meaning, connection, and a sense of purpose through helping others.
Correct Answer is C
Explanation
This response acknowledges the client's need for assistance while redirecting the focus towards exploring alternative solutions. It demonstrates the nurse's willingness to help and initiates a collaborative problem-solving approach. By engaging in a discussion about available resources, the nurse can help the client explore options such as home delivery services, community support programs, or involving family and friends in assisting with grocery shopping.
Let's review the other options and explain why they are not the most appropriate responses:
A. "I won't be able to shop for you today because I have to get home to my family." This response lacks empathy and doesn't address the client's needs. It is important for the nurse to prioritize the client's well-being and explore appropriate solutions rather than providing personal reasons for not being able to assist.
B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response overlooks the client's current limitations and implies that the client should solely rely on their own abilities, which may not be feasible or practical for the client.
D. "I would be happy to do whatever I can to help you." While this response conveys the nurse's willingness to assist, it is important to remember that shopping and performing personal errands are typically outside the scope of a home care nurse's responsibilities. It is more appropriate to explore other resources and options to address the client's needs effectively.
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