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. Instruct the client to cough as the suction tip is removed: While encouraging coughing helps clear secretions, it is not safe to ask a client to cough before suctioning; suctioning should be done with the catheter in place to remove secretions effectively.

B. Apply a water soluble lubricant to the catheter: Lubrication is not recommended for tracheostomy suctioning because it can introduce infection or interfere with effective suctioning.

C. Instill 3 mL of 0.9% sodium chloride before suctioning: Routine saline instillation is no longer recommended as it may increase the risk of infection, hypoxia, and airway irritation without improving secretion clearance.

D. Wear protective goggles while performing the procedure: Protective eyewear is essential to prevent exposure to secretions and reduce the risk of infection or contamination during tracheostomy suctioning.

A. Noncompliance with treatment regimen. B. Disturbed Body Image. C. Interrupted Family Processes. D. Imbalanced Nutrition: less than body requirements.

Correct Answer is D

Explanation

A. Noncompliance with treatment regimen: While noncompliance can affect recovery, it is secondary to the immediate physiological risks posed by malnutrition. Addressing noncompliance becomes relevant after stabilizing the client’s health.

B. Disturbed Body Image: Distorted body image is a core psychological issue in anorexia nervosa, but it does not pose an immediate threat to the client’s life. Interventions targeting body image are important but not the first priority.

C. Interrupted Family Processes: Family dynamics may influence the client’s condition and recovery, yet they are not life-threatening. Family interventions are supportive and adjunctive to stabilizing the client’s nutritional status.

D. Imbalanced Nutrition: less than body requirements: Malnutrition directly threatens the adolescent’s physiological stability, affecting cardiovascular, gastrointestinal, and endocrine function. Correcting nutritional deficits and preventing complications such as electrolyte imbalance or organ failure is the highest priority in care planning.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

Correct Answer is D

Explanation

When planning care for an adolescent with anorexia nervosa, which nursing problem has the highest priority?

Correct Answer is D

Explanation

A parent brings their child, who has a history of asthma, to the emergency department (ED). The child is wheezing and speaking one word between each breath. The child is anxious, tachycardic, and has labored respirations. Which assessment is most important for the nurse to obtain?

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