A nurse is assisting with the care of a client who has dementia.
Which of the following actions should the nurse take?

Provide the client with a dark environment for sleeping.

Repeat orientation asks until the client gives a correct response.

Give the client a list of foods to choose from for dinner.

Make a personal introduction to the client at each interaction.

Answer and Explanation

The Correct Answer is D

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. .

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Correct Answer is ["A","D","E"]

Explanation

Choice A rationale: Maintaining a low stimulation environment helps reduce agitation and confusion in clients with delirium. Minimizing noise, light, and activity can create a calming atmosphere, which is essential for clients experiencing sensory overload and cognitive disturbances.

Choice B rationale: Alternating nursing staff daily can disrupt continuity of care, which may increase the client's confusion and anxiety. Familiarity with consistent caregivers helps provide a stable environment, promoting better management of delirium symptoms.

Choice C rationale: Providing the client with limited information about their diagnosis is not helpful. It is important to keep the client informed to the extent they can understand, which helps in reorienting them and reducing confusion about their situation.

Choice D rationale: Approaching the client slowly is crucial in managing agitation and confusion. A calm and non-threatening approach helps in gaining the client's trust, making them feel more secure and reducing the likelihood of aggressive behavior.

Choice E rationale: Reorienting the client to person, place, and time frequently is vital in managing delirium. Regular reorientation helps the client regain a sense of reality and reduces confusion. This intervention is key to improving cognitive function and managing disorientation.

A. Implement 24-hr one-to-one nursing observation. B. Document the client's behavior every 2 hr. C. Restrict interactions with other clients. D. Administer prescribed medication via the IM route.

Correct Answer is A

Explanation

Choice A rationale

Implementing 24-hr one-to-one nursing observation is crucial for ensuring the safety of a client who has overdosed and is at risk of self-harm.

Choice B rationale

Documenting the client's behavior every 2 hr is not sufficient to ensure their safety in an overdose situation.

Choice C rationale

Restricting interactions with other clients does not directly address the immediate risk of harm to the client.

Choice D rationale

Administering prescribed medication via the IM route does not provide the necessary supervision for a client at high risk of self-harm.

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A nurse is assisting with the care of a client who has dementia.
Which of the following actions should the nurse take?