A nurse in a long-term care facility is caring for a client with dementia who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?

Take the client for a walk and ask them to talk about their family

Administer alprazolam to decrease their anxiety

Administer olanzapine to decrease their agitation

Take the client to their room so they will not upset others

Answer and Explanation

The Correct Answer is A

Choice A reason: Engaging the client in a walk and family discussion uses therapeutic communication and redirection, common in dementia care. This non-pharmacological approach validates emotions, reduces distress, and promotes calmness by shifting focus to positive memories, aligning with person-centered care principles to address emotional needs first.

Choice B reason: Alprazolam, a benzodiazepine, reduces anxiety but carries risks like sedation and falls in dementia patients. Pharmacological interventions should be secondary to non-pharmacological approaches, as they may exacerbate confusion or dependency. Addressing emotional distress through engagement is preferred before considering medications for anxiety management.

Choice C reason: Olanzapine, an antipsychotic, is used for severe agitation or psychosis in dementia. It poses risks like sedation, extrapyramidal symptoms, and increased mortality in elderly patients. Non-pharmacological interventions, like redirection, are prioritized to manage emotional distress safely, reserving medications for when behavioral approaches fail.

Choice D reason: Isolating the client in their room may increase distress and agitation in dementia patients, as it does not address their emotional needs. Social isolation can worsen confusion and feelings of abandonment. Therapeutic engagement, such as redirection or validation, is more effective in calming the client and fostering trust.

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Correct Answer is D

Explanation

Choice A reason: Showing positions for holding a newborn addresses the psychomotor domain, teaching physical skills. The affective domain involves emotions and attitudes, not physical techniques. This action helps parents learn how to feed but does not explore their feelings or beliefs, which is the focus of affective learning.

Choice B reason: Explaining bottle-warming steps targets the cognitive domain, focusing on knowledge and procedure. It does not address emotions or attitudes, which are central to the affective domain. This action provides technical understanding but does not engage the parents’ feelings or values about newborn care.

Choice C reason: Having parents demonstrate diaper changing is a psychomotor activity, emphasizing skill acquisition. The affective domain involves feelings and attitudes, not physical tasks. While this builds confidence, it does not directly address emotional engagement or beliefs, which are necessary for affective learning in this context.

Choice D reason: Asking about breastfeeding views targets the affective domain by exploring parents’ emotions, beliefs, and attitudes. This encourages reflection on personal values, fostering emotional engagement with newborn care. Addressing these feelings helps build confidence and commitment, aligning with affective learning goals in nursing education.

A. Urinary retention B. Decreased fluid volume risk C. Altered skin integrity D. Altered urinary elimination

Correct Answer is B

Explanation

Choice A reason: Urinary retention, the inability to empty the bladder, is unlikely with diuretics, which increase urine output. Diuretics reduce fluid volume by enhancing renal excretion, not causing retention. This concern is irrelevant, as the client’s increased output suggests effective diuresis, not bladder dysfunction or obstruction.

Choice B reason: Decreased fluid volume risk is a primary concern with diuretics, which increase urine output, potentially causing dehydration or electrolyte imbalances (e.g., hypokalemia). Education on fluid intake, monitoring weight, and recognizing dehydration symptoms is critical to prevent hypovolemia, ensuring safe diuretic use and maintaining physiological stability.

Choice C reason: Altered skin integrity may occur secondary to dehydration (dry skin) but is not the primary concern with diuretics. The main risk is fluid volume loss, which can lead to systemic complications like hypotension. Education should focus on fluid balance rather than skin, which is a secondary issue.

Choice D reason: Altered urinary elimination, such as incontinence, is not the primary concern, as diuretics increase output, not disrupt elimination patterns. While frequent urination may occur, the critical issue is fluid volume loss, which poses greater risks like dehydration or electrolyte imbalances, necessitating education on fluid management.

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A nurse in a long-term care facility is caring for a client with dementia who is upset over not being able to find their spouse, who passed away years ago. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

indicate the nurse is addressing the affective domain of learning?

Correct Answer is D

Explanation

A client is taking a diuretic that increases urinary output. What nursing concern is appropriate to base an educational plan?

Correct Answer is B

Explanation

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