A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss.

Which of the following strategies should the nurse include in the plan?

Maintain low-level lights in common areas.

Give the client several meal options at lunchtime.

Confront the client regarding inappropriate behavior.

Use symbols in the communal room signage.

Answer and Explanation

The Correct Answer is D

A. Maintain low-level lights in common areas. Low-level lighting can increase confusion and the risk of falls, especially for clients with memory loss. It is important to have adequate lighting to promote a safe environment and help with orientation. Well-lit areas can reduce disorientation and anxiety in clients who are confused or have memory issues.

B. Give the client several meal options at lunchtime. For clients with memory loss and confusion, it is better to provide simple choices or pre-selected meals to reduce decision-making stress and confusion.

C. Confront the client regarding inappropriate behavior. Confronting a client with memory loss or confusion about inappropriate behavior can increase agitation, anxiety, and defensive reactions.

D. Use symbols in the communal room signage. Symbols and pictures can help clients with memory loss navigate their environment more easily because they may have difficulty reading or comprehending written language. Visual cues such as symbols in signage can improve orientation and independence, helping the client feel more comfortable in their surroundings.

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Correct Answer is C

Explanation

Using a cool-mist vaporizer in the baby's room can help provide moisture and relieve nasal congestion, especially during cold or dry weather. It can help ease breathing and improve the baby's comfort.

"I will leave the plastic covering on the crib mattress": This statement is incorrect. The plastic covering should be removed from the crib mattress before placing the baby in the crib. The plastic covering poses a suffocation risk and should not be used.

"I will lay my baby's head on a pillow while he is in the crib": This statement is incorrect. Pillows should not be used in the crib for infants. They increase the risk of suffocation and can pose a hazard to the baby. The crib should be free of pillows, blankets, stuffed animals, or any other loose items.

"I will leave my baby's bib on while he is sleeping": This statement is incorrect. Bibs should be removed before placing the baby in the crib or while the baby is sleeping to prevent the risk of suffocation. Loose items around the baby's neck can pose a strangulation hazard.

A. State expectations for the client's behavior. B. Request security personnel restrain the client. C. Place the client in seclusion. D. Debrief staff members about the conflict.

Correct Answer is A

Explanation

The correct answer is Choice A.

Choice A rationale: By stating expectations for the client’s behavior, the nurse is addressing the immediate situation and setting clear boundaries.This intervention allows the nurse to assertively communicate with the client, reminding them of appropriate behavior and potentially diffusing the situation 1.

Choice B rationale: Requesting security personnel to restrain the client should be a last resort, used only when the client poses a significant risk to themselves or others and all other de-escalation techniques have failed. Restraint can be traumatic and has potential physical and psychological risks.

Choice C rationale: Placing the client in seclusion is another measure that should be used sparingly and only when necessary for the safety of the client or others. It’s important to try less restrictive measures first, such as verbal de-escalation techniques or offering a quiet, private space where the client can regain control.

Choice D rationale: Debriefing staff members about the conflict is an important step, but it should not be the first action. The immediate priority is to ensure the safety of all clients and to de-escalate the situation.

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A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss. Which of the following strategies should the nurse include in the plan?

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A nurse in an adult day care facility is contributing to the plan of care for a client whose family reports recent confusion and memory loss.

Which of the following strategies should the nurse include in the plan?