The nurse is providing care for an elderly client who has dementia. Interventions used would include: (SELECT ALL THAT APPLY)

modifying the environment to compensate for changes in cognitive status

using short. simple sentences when communicating with the client

allowing the client to participate in performing ADLS to the best of their ability

discouraging family members from visiting.

giving the client choices with a wide variety of options.

Answer and Explanation

Correct Answer : A,B,C,E

A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.

B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.

C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.

E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.

D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.

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Correct Answer is D

Explanation

D. This statement exemplifies the ethical principle of fidelity, also known as faithfulness or commitment. Fidelity involves keeping promises, being reliable, and fulfilling commitments made to patients. By returning promptly with the pain medication as promised, the nurse demonstrates fidelity by honoring their commitment to the patient's care and comfort.

A. This statement reflects the ethical principle of justice, which emphasizes fairness and equality in treatment for all patients. Justice ensures that resources and treatments are distributed fairly among individuals.

B This statement demonstrates the ethical principle of nonmaleficence, which focuses on preventing harm and minimizing risks to patients. It emphasizes the nurse's commitment to avoiding harm or injury to the patient.

C. This statement relates to truth-telling or veracity, which involves providing honest and accurate information to patients about their care, procedures, and potential outcomes. It reflects transparency and respect for patient autonomy.

A. Axillary B. Skin C. Oral D. Rectal

Correct Answer is D

Explanation

D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.

A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.

B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.

C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.

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The nurse is providing care for an elderly client who has dementia. Interventions used would include: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is considering ethical principles during rounds. Which nursing statement demonstrates the principle of fidelity?

Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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