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.
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Related Questions
Correct Answer is B
Explanation
Clients have the right to make informed decisions about their own healthcare, including the right to refuse treatment. It is important to respect the client's autonomy and honor their decision if they choose to refuse the treatment. The nurse should provide the client with information about the potential benefits and risks of the treatment, as well as any alternatives, and support the client in making an informed decision.
Let's examine why the other choices are incorrect:
A. "You will be discharged sooner if you have the prescribed ECT treatments." This statement does not address the client's right to refuse treatment and instead focuses on potential consequences of refusing. It is important to respect the client's autonomy and prioritize their right to make decisions about their own healthcare.
C. "You are admitted to a mental health facility and must follow the provider's orders." While clients in a mental health facility may have certain treatment plans, including ECT, it is still important to respect their right to refuse treatment. Admitting to a facility does not negate the client's right to make decisions about their own care.
D. "You have already signed the consent form, so you cannot refuse today's treatment." Signing a consent form does not mean that the client loses their right to refuse treatment. Consent forms are signed to acknowledge that the client has been provided with information about the treatment and has agreed to undergo it voluntarily. However, the client still has the right to change their mind and refuse the treatment at any time.
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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