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 B

Explanation

B Watching exciting or stimulating movies, especially horror movies, before bedtime can hinder sleep onset. Such activities can increase arousal and make it more difficult to relax and fall asleep. This statement suggests a lack of understanding of good sleep hygiene practices. Further teaching is needed to discourage stimulating activities before bedtime.

A. Consistency in sleep schedule helps regulate the body's internal clock (circadian rhythm) and can promote better sleep quality. There is no need for further teaching regarding this statement.

C. This statement reflects good sleep hygiene advice. Getting up and engaging in a quiet, boring activity if unable to fall asleep after about 30 minutes can prevent frustration and anxiety associated with lying awake in bed. This practice helps condition the mind to associate the bed with sleep rather than wakefulness. There is no need for further teaching regarding this statement.

D. This statement also reflects good sleep hygiene practices. Going to bed when feeling naturally tired can enhance the ability to fall asleep quickly. It aligns with the concept of associating the bed with sleepiness and promotes sleep onset. There is no need for further teaching regarding this statement.

A. pump the cuff up again immediately before releasing it. B. use the client's radial pulse to determine how high to pump up the cuff C. obtain another cuff and take the blood pressure again in 30 minutes. D. release the cuff completely and wait two minutes before retaking the blood pressure.

Correct Answer is D

Explanation

D. When uncertain about the endpoint of Korotkoff sounds, releasing the cuff completely allows the blood flow to return to normal in the arm. After waiting for about two minutes, the nurse can reinflate the cuff and begin the measurement process again. This approach helps ensure accurate measurement by resetting conditions and allowing for a clearer determination of when Korotkoff sounds start and stop.

A. This option is not recommended because re-inflating the cuff immediately could lead to incorrect readings due to inaccurate pressure settings or discomfort for the client. It does not address the issue of determining the endpoint of the Korotkoff sounds.

B. This technique involves palpating the radial pulse while inflating the cuff and then inflating the cuff until the pulse is no longer palpable. This method can help ensure the cuff is inflated to an appropriate pressure level, which is typically about 30 mmHg above the point where the radial pulse disappears.

However, this option does not directly address the uncertainty about when to listen for the Korotkoff sounds to stop.

C. This option is not practical for addressing the immediate uncertainty during the current blood pressure measurement. Waiting 30 minutes to retake the blood pressure with a different cuff may delay necessary assessment and intervention.

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

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Naxlex Comprehensive Predictor Exams

Which statement made by a client experiencing insomnia indicates a need for the nurse to do further teaching

Correct Answer is B

Explanation

The nurse, while obtaining the blood pressure reading of a client, is uncertain when the muffled sounds have ended. What is the nurse's best action at this time?

Correct Answer is D

Explanation

The nurse assesses that a client is experiencing spiritual distress. What should be the nurse's primary intervention?

The nurse is caring for hospitalized clients. Which nursing action requires the nurse to use sterile gloves?

A non-critical care nurse is part of the team in a "code blue resuscitation effort. The medical resident hands the nurse an unlabeled syringe and says. Give this to the client IV push STAT Whet response by the nurse appropriate in this emergency situation

The nurse understands that which part(s) of an IV administration set must remain sterile? The: (SELECT ALL THAT APPLY)

The nurse knows that many medications given to clients have predictable, secondary effects which may be harmful or may be beneficial. The nurse always includes these effects in client teaching.

The nurse realizes that a medication error may have occurred. The nurse's first responsibility is to: