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 D

Explanation

A. Recommend that he avoid fast food restaurants until he is familiar with his prescribed diet: Restricting social activities can lead to feelings of isolation and negatively affect adherence. It does not teach the adolescent practical skills for managing diabetes in real-life situations.

B. Encourage him to find activities to do with his friends that do not involve eating: While alternative activities are beneficial, avoiding meals with friends is not realistic for a teen. The goal is to promote self-management skills, not complete avoidance of social situations.

C. Advise him to take his own food with him when going to fast food restaurants with his friends: Bringing food may help in some situations, but it does not encourage the adolescent to make informed choices or learn how to navigate typical social eating environments.

D. Assist him in identifying popular fast foods that are within his meal plan for diabetes: Teaching the teen how to select appropriate options from common fast food menus empowers him to adhere to his diet while maintaining social interactions. This approach promotes self-management, independence, and realistic coping strategies.

A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days. B. Update the client and family regarding the COVID-19 vaccines that are available. C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility. D. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE.

Correct Answer is D

Explanation

A. Explain to the client to inform others that they may have been potentially exposed in the last 14 days: While educating the client about notifying contacts is important, it does not prevent immediate transmission within the healthcare setting. It is a secondary measure.

B. Update the client and family regarding the COVID-19 vaccines that are available: Providing vaccine information is useful for long-term prevention but does not address the urgent need to reduce the risk of transmission from a potentially contagious client.

C. Notify the charge nurse the client will need assignment to the COVID-19 specified area of the facility: Assigning the client to a designated area is important for infection control, but the immediate priority is preventing exposure to others while awaiting placement.

D. Isolate the client from other clients, family, and healthcare workers not wearing proper PPE: Immediate isolation is the most critical action to prevent the spread of COVID-19. This protects other clients, visitors, and staff while testing and further management are arranged.

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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

A 15-year-old male client was recently diagnosed with type 1 diabetes mellitus. He tells the nurse that he is having difficulty adhering to his meal plan when he is with his friends. Which nursing intervention is best for the nurse to implement?

Correct Answer is D

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

Correct Answer is D

Explanation

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