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 C

Explanation

A. Monitor for desquamation and normal flora overgrowth: While monitoring skin integrity is important, this does not directly prevent the primary complication of scabies, which is secondary bacterial infection from scratching.

B. Wash skin between application of topical antiparasitic doses: Washing between doses can remove the medication prematurely, reducing its effectiveness. The lotion should remain on for the prescribed time before being washed off.

C. Keep the child's nails short and encourage use of hand mittens: Trimming nails and using mittens reduce scratching and skin breakdown, which lowers the risk of bacterial superinfection, the main complication of scabies in children.

D. Shave the body hair before applying the scabicide lotion: Shaving is not recommended, as scabicide is effective when applied to the skin surface. Shaving may cause irritation and increase discomfort without improving treatment outcomes.

A. Offer to discuss the client's health status with each of the adult children. B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children. C. Gather information regarding how long it will take for the children to arrive. D. Explain that the client will start to lose consciousness and the body systems will slow down.

Correct Answer is D

Explanation

A. Offer to discuss the client's health status with each of the adult children: While involving family in discussions is important, the immediate question from the spouse is about recognizing signs of imminent death. Directly explaining the physiological changes is more appropriate at this moment.

B. Reassure the spouse that the healthcare provider (HCP) will notify when to call the children: Waiting for the HCP to give a signal does not provide the spouse with the knowledge they are seeking. It may delay preparation and increase anxiety during the final hours.

C. Gather information regarding how long it will take for the children to arrive: While logistical planning is helpful, it does not address the spouse’s question about recognizing imminent death and understanding what to expect.

D. Explain that the client will start to lose consciousness and the body systems will slow down: Providing clear, compassionate information about the expected signs of dying helps the spouse recognize that death is near, allows family members to prepare emotionally, and facilitates meaningful final interactions with the client.

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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 care for a child who is suffering from persistent itching due to scabies. Which measure should the nurse implement to minimize this child's risk for complications?

Correct Answer is C

Explanation

An adult client was diagnosed with stage IV lung cancer three weeks ago. The client's spouse approaches the nurse and asks, "How will I know that my husband's death is imminent? Our two adult children want to be here when their father dies." Which is the best response by the nurse?

Correct Answer is D

Explanation

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