An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

Reorient the client while performing assessment.

Lower the lighting in the client's room.

Switch to a familiar topic after acknowledging client's feelings.

Remind the client that his spouse is deceased.

Explain the rehabilitation regimen to the client.

Answer and Explanation

Correct Answer : B,C

A. Reorient the client while performing assessment: Reorienting a client with acute dementia during periods of distress can increase confusion and agitation. Forcing orientation is often counterproductive and may escalate anxiety.

B. Lower the lighting in the client's room: Reducing harsh lighting can help decrease overstimulation and agitation, creating a calmer environment for a client experiencing acute confusion or distress.

C. Switch to a familiar topic after acknowledging client's feelings: Validating the client’s emotions and then gently redirecting to familiar topics can reduce anxiety, provide comfort, and improve cooperation without causing confrontation.

D. Remind the client that his spouse is deceased: Confronting the client with reality in a distressed state can increase agitation, fear, and confusion. Reality orientation should be approached cautiously, if at all, during acute episodes.

E. Explain the rehabilitation regimen to the client: While education about care is generally important, a client in acute dementia may not be able to process detailed explanations. This intervention does not address immediate emotional distress or safety.

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Correct Answer is B

Explanation

A. Before going to bed: Bedtime glucose checks may be recommended for some clients, especially those on insulin, but this timing is individualized. It is not universally required for every client with diabetes.

B. During acute illness: Any client with diabetes, regardless of age or type, should monitor glucose closely during acute illness. Illness can cause stress-induced hyperglycemia or unpredictable fluctuations, requiring more frequent testing to guide management.

C. Prior to exercising: Checking glucose before exercise is important for clients at risk of hypoglycemia, especially those using insulin or certain oral agents. However, this is not necessary for all clients, particularly those with type 2 diabetes controlled by diet alone.

D. Immediately after meals: Postprandial monitoring is useful in some cases to evaluate mealtime insulin effectiveness or dietary impact, but it is not universally recommended for every diabetic client. Its use depends on individualized treatment plans.

A. Place the client in the Trendelenburg position. B. Remove the client's legs from the stirrups. C. Instruct the client to take deep breaths. D. Place a wedge under the client's hip.

Correct Answer is D

Explanation

A. Place the client in the Trendelenburg position: While this position may increase venous return, it does not address the underlying cause in a pregnant client, which is usually aortocaval compression by the uterus. Simply tilting the table may be less effective than proper lateral displacement.

B. Remove the client's legs from the stirrups: Removing the legs may relieve some discomfort but does not correct the maternal hypotension caused by pressure on the inferior vena cava. Additional interventions are needed to improve circulation.

C. Instruct the client to take deep breaths: Deep breathing may help with anxiety or mild shortness of breath but does not resolve the hemodynamic compromise caused by supine hypotensive syndrome.

D. Place a wedge under the client's hip: Placing a wedge under the right or left hip tilts the uterus off the inferior vena cava, improving venous return, cardiac output, and blood pressure. This is the priority action to relieve dizziness, pallor, and diaphoresis in a pregnant client at 26 weeks’ gestation.

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An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Correct Answer is B

Explanation

After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. Which action should the nurse implement?

Correct Answer is D

Explanation

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