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 D
Explanation
Answer: (D) Suppression
Rationale:
A) Dissociation: Dissociation involves a disconnection from reality or the separation of thoughts, memories, or identity from conscious awareness. In this scenario, the client is not displaying any signs of disconnecting from reality or avoiding awareness of the situation through dissociation, making this defense mechanism unlikely.
B) Projection: Projection occurs when an individual attributes their own unacceptable thoughts or feelings to others. The client in this situation is not blaming others or attributing their actions to someone else, so projection is not the defense mechanism being demonstrated here.
C) Intellectualization: Intellectualization involves using reasoning or logic to avoid emotional stress or anxiety. While the client does mention logical-sounding plans about things working out next week, their overall response does not primarily reflect an avoidance of emotion through reasoning, so intellectualization is not the correct choice.
D) Suppression: Suppression is the conscious decision to delay paying attention to an emotion or need in order to cope with the present situation. The client acknowledges the stress of being fired but chooses to push aside their distress by stating that "everything will work out somehow next week," indicating they are consciously choosing to set aside their anxiety for the time being. This aligns with the concept of suppression.
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.
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