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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 C

Explanation

The appropriate response for the nurse in this situation would be: "I'll just sit here with you for a few minutes then."
This response acknowledges the client's expressed desire not to talk and respects their boundaries. It shows support and presence by offering companionship without pressuring the client to discuss their feelings. The nurse's willingness to sit with the client demonstrates empathy and provides a sense of comfort and reassurance.
The other options are not as appropriate:

1. "It might help you feel better if you talk about it." This response disregards the client's stated preference not to talk and may create a sense of pressure or intrusiveness. It is important to respect the client's autonomy and readiness to share their feelings.
2. "Why are you feeling so down?" This response directly asks the client to explain their feelings, which they have already indicated they do not want to discuss. It can be seen as intrusive and may make the client feel uncomfortable or defensive.
3. "I understand. I've felt like that before, too." While empathy is important, this response brings the focus back to the nurse's own experiences, potentially diverting the attention from the client. It is important for the nurse to remain focused on the client's needs and create a supportive environment for them to express their feelings if they choose to do so.

A. "Everything will be okay until morning. You can speak with your provider then." B. "You seem to be very upset about something. Tell me about it." C. "Go back to your room, and I'll try to get in touch with your provider in the morning." D. "Why don't you wait to speak to your provider in the morning?"

Correct Answer is B

Explanation

This response reflects active listening and demonstrates empathy towards the client's feelings. It acknowledges the client's distress and encourages them to express their concerns and thoughts. By actively listening and showing genuine interest, the nurse can gather more information to assess the client's needs and determine the appropriate course of action.

Let's discuss why the other options are incorrect:

A. "Everything will be okay until morning. You can speak with your provider then." This response may dismiss or invalidate the client's current distress and fails to address their immediate concerns. It suggests waiting until morning without exploring the reasons behind the client's urgency.

C. "Go back to your room, and I'll try to get in touch with your provider in the morning." While the intention may be to offer assistance, this response does not address the client's emotional state or explore the reasons for their demand to see the provider. It may also not address the client's immediate needs and concerns.

D. "Why don't you wait until the morning? The provider will be available then." This response may come across as dismissive and may not acknowledge the client's current distress. It does not encourage the client to express their concerns or provide an opportunity for open communication.

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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 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.