A client has recently been placed in a long-term care facility because of marked confusion and inability to perform most activities of daily living. Which nursing intervention is most appropriate to maintain the client's self-esteem?
Modifying the daily schedule often to maintain variety
Allowing the client to choose between two different outfits
Leaving the client alone in the bathroom
Assigning a variety of caregivers
The Correct Answer is B
Choice A reason: Frequently modifying the daily schedule can increase confusion and anxiety in clients with cognitive impairment. Consistency is more beneficial than variety in this population.
Choice B reason: Allowing the client to make simple choices, such as selecting between two outfits, promotes autonomy and self-esteem. It provides a sense of control without overwhelming the client. This is the most appropriate intervention.
Choice C reason: Leaving the client alone in the bathroom may compromise safety and increase risk of falls or injury. It does not promote self-esteem and may cause distress.
Choice D reason: Assigning a variety of caregivers can reduce consistency and increase confusion. Clients with marked confusion benefit from familiar caregivers to build trust and security.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Conduct disorder involves persistent patterns of violating societal norms and the rights of others. Involuntary motor or vocal tics are not characteristic of conduct disorder.
Choice B reason: Tourette’s disorder is characterized by multiple motor tics and at least one vocal tic. Blinking and coughing are examples of involuntary motor and vocal tics, making this the most appropriate diagnosis.
Choice C reason: Oppositional defiant disorder involves defiance, irritability, and argumentative behavior toward authority figures. It does not include involuntary tics.
Choice D reason: Autism spectrum disorder involves social communication deficits and restricted, repetitive behaviors. While stereotyped movements may occur, involuntary tics such as blinking and coughing are not typical features.
Correct Answer is B
Explanation
Choice A reason: Encouraging the patient to talk more about anger may be therapeutic, but safety assessment must come first when violent statements are made.
Choice B reason: Assessing risk of harm is the priority. The nurse must determine if the client has intent, plan, or means to act on homicidal statements. Safety overrides all other interventions.
Choice C reason: Contacting parents and police is premature without assessing actual risk. Reporting without assessment could violate confidentiality and escalate the situation unnecessarily.
Choice D reason: Instructing the patient not to talk that way invalidates feelings and does not address safety concerns.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
