A client who delivered a healthy newborn 4 weeks ago calls her provider's office and tells the nurse, "This baby constantly cries.
My partner works all the time, and I can't take any more.”. Which of the following responses is the nurse's priority?

Choice A rationale

Documenting the client's behavior every 1 hour is not sufficient in this case. Restraints require continuous monitoring and more frequent documentation to ensure the client's safety.

Choice B rationale

Minimizing staff interactions could increase the client's agitation and sense of isolation, which is counterproductive to their well-being.

Choice C rationale

Restraint orders need to be reviewed and renewed more frequently than every 24 hours to ensure continued necessity and appropriateness. Typically, restraint orders should be reviewed every 4 hours for adults.

Choice D rationale

Providing range-of-motion exercises every 2 hours helps to prevent complications associated with immobility, such as muscle atrophy, contractures, and pressure ulcers.

Choice A rationale

Providing the client with a dark environment for sleeping can aid in better rest and sleep quality, which is particularly important for clients with dementia who may have disrupted sleep patterns. However, it's essential to ensure that the environment is safe to prevent any accidents due to poor visibility.

Choice B rationale

Repeating orientation tasks until the client gives a correct response can help reinforce their memory and cognitive function. This practice is known as reality orientation, which is a therapeutic technique used to improve awareness of time, place, and person in clients with dementia.

Choice C rationale

Giving the client a list of foods to choose from for dinner provides autonomy and encourages decision-making. It helps in maintaining cognitive function and personal preferences, which can positively impact their mental health and quality of life.

Choice D rationale

Making a personal introduction to the client at each interaction helps in establishing a connection and reducing confusion. Clients with dementia often have short-term memory loss, so frequent reintroduction can provide reassurance and familiarity, contributing to their sense of security. .