A home health nurse is providing education for the family of a client who has dementia. Which of the following interventions should the nurse recommend?

Place a soft rug in front of the client's chair.

Set the client's water heater at 140° F.

Encourage the client to take a 1 hr nap in the afternoon.

Limit fluid intake after the client's evening meal.

Answer and Explanation

The Correct Answer is C

Choice A reason: Placing a soft rug in front of the client’s chair increases the risk of tripping and falling. Clients with dementia often have impaired judgment, coordination, and gait instability. Loose rugs are a well-known environmental hazard in home safety assessments, and therefore this intervention is unsafe.

Choice B reason: Setting the water heater at 140° F is dangerous because clients with dementia may not recognize the risk of burns. Safe water heater settings are typically recommended at or below 120° F to prevent scalding injuries. High temperatures pose a significant safety risk for cognitively impaired individuals.

Choice C reason: Encouraging a 1-hour nap in the afternoon is beneficial. Clients with dementia often experience fatigue, irritability, and sundowning (worsening confusion in the evening). A structured rest period helps reduce agitation, improves mood, and supports overall functioning. This intervention promotes both safety and comfort.

Choice D reason: Limiting fluid intake after the evening meal can lead to dehydration and urinary tract infections. While nighttime incontinence may be a concern, restricting fluids is not recommended because hydration is critical for cognitive and physical health. Instead, toileting schedules and protective measures should be used.

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Correct Answer is C

Explanation

Choice A reason: Selective inattention occurs in moderate anxiety, where the client begins to block out or ignore certain stimuli due to difficulty focusing. It is not characteristic of mild anxiety, where awareness is still intact.

Choice B reason: Urinary frequency is a physical manifestation of severe anxiety due to autonomic nervous system activation. It is not expected in mild anxiety.

Choice C reason: Sharpened perceptions are characteristic of mild anxiety. The client is more alert, attentive, and able to focus better on the environment. Mild anxiety can enhance problem-solving and concentration.

Choice D reason: Voice tremors are associated with moderate to severe anxiety, where physiological symptoms become more pronounced. They are not typical of mild anxiety.

A. "Your partner should not be allowed to take out their stress on your child." B. "Why do you think this will not happen again?" C. "It's up to you as the parent to report this incident to the authorities." D. "Your child will be privately interviewed about the incident." E. Change in level of consciousness

Correct Answer is D

Explanation

Choice A reason: While this statement is true, it is confrontational and does not address the nurse’s legal and professional responsibility. Nurses must prioritize child safety and follow mandated reporting laws rather than offering judgmental statements.

Choice B reason: Asking the parent why they think it will not happen again is inappropriate. It places responsibility on the parent and may minimize the seriousness of the abuse. The nurse’s role is to protect the child, not to debate with the caregiver.

Choice C reason: Reporting suspected child abuse is not optional or left to the parent. It is a legal obligation of healthcare providers. Suggesting that it is the parent’s responsibility misrepresents the nurse’s duty and could result in failure to protect the child.

Choice D reason: Informing the parent that the child will be privately interviewed is appropriate. This ensures the child’s voice is heard without parental influence and allows professionals to assess the situation accurately. It also communicates the seriousness of the incident while maintaining professionalism

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A home health nurse is providing education for the family of a client who has dementia. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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