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 D
Explanation
Respecting and honoring the autonomy of the clients is important in a mental health setting. Allowing clients to determine the boundaries of the nurse-client relationship empowers them to have control over their own treatment and fosters a sense of autonomy. It encourages clients to express their needs, preferences, and comfort levels in the therapeutic relationship, which can contribute to a more collaborative and effective treatment process.
The other options mentioned are not appropriate actions for the nurse to take:
A. Orienting clients to their responsibilities on the unit is an important task, but it is not specific to the context of a community meeting. It is more relevant during individual client orientations or at the beginning of their admission.
B. Focusing on client weaknesses to increase adaptation is not a therapeutic approach. It is important to focus on clients' strengths and support their growth and development rather than emphasizing weaknesses.
C. Planning to discuss any topic presented by clients can be unfeasible or not relevant in a community meeting. It is essential to have structure and purpose in group discussions to facilitate meaningful interactions.
Correct Answer is C
Explanation
Involuntary commitment is a legal process where an individual is admitted to a psychiatric facility against their will due to a perceived risk of harm to themselves or others. The primary concern in involuntary commitment is the safety and well-being of the individual and those around them.
Therefore, it is important for the nurse to inform the client's family about the reason for the involuntary commitment, emphasizing that the client's behavior poses a threat to themselves or others.
incorrect:
A. "A psychiatrist determines that the client's behavior is irrational." This statement focuses on the client's behavior being irrational, which is not the primary criteria for involuntary commitment. It is more important to emphasize the potential harm the client may cause to themselves or others.
B. "The client is unable to manage the affairs necessary for daily life." While this may be a factor contributing to the need for psychiatric treatment, it is not the specific reason for involuntary commitment. The main concern is the risk of harm associated with the client's behavior.
D. "The client has been accused of breaking the law." Involuntary commitment is not based on accusations of breaking the law. It is primarily focused on the safety and well-being of the individual and the potential risk they pose to themselves or others.
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