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 C

Explanation

C. This reflex is an important protective mechanism that prevents objects from entering the throat and causing choking. Assessing the gag reflex before oral care can help ensure the safety of the client, especially if they have difficulty swallowing or are at risk for aspiration.

A. It's important to assess if the client is experiencing any pain, as oral care procedures can sometimes cause discomfort, especially if the client has oral lesions or sensitive gums. However, it is not a priority.

B. Presence of saliva: Saliva is essential for oral health, as it helps to cleanse the mouth and buffer acids produced by bacteria. Assessing the amount of saliva can indicate the overall oral hydration status and potential risk of dry mouth (xerostomia).

D. assessing the condition of the skin around the mouth and on the lips is important. It can reveal issues such as dryness, cracking, lesions, or signs of infection but not directly related to oral care.

A. give the assistant a written warning to be placed in the personnel file. B. act as a role model and resource in identifying alternative solutions. C. perform the task for the assistant so the assistant is not embarrassed. D. give the assistant a second task so that another opportunity to succeed is provided.

Correct Answer is A

Explanation

A. Giving a written warning is a serious disciplinary action that should only be considered after other steps to support and assist the assistant have been taken. It does not promote a supportive or constructive approach to resolving the issue.

B. This option involves the nurse providing guidance and support to the assistant. By acting as a role model, the nurse can demonstrate the correct way to approach the task and provide alternative solutions or techniques. This approach encourages learning and professional development for the assistant.

C. While this may temporarily resolve the issue, it does not address the assistant's competency or provide an opportunity for learning and growth. It may also undermine the assistant's confidence and independence in performing the task.

D. While providing another task might offer another chance for success, it does not directly address the current difficulty with the delegated task. The nurse should focus on addressing the specific challenge at hand before assigning additional tasks.

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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

A client requires complete care with ADL's. Before providing oral care, the nurse should assess for which of the following?

Correct Answer is C

Explanation

The nurse's assistant is having difficulty carrying out a delegated task. The first step the nurse should take is to:

Correct Answer is A

Explanation

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

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