A nurse is caring for a client who has dementia and is experiencing confusion. Which of the following actions should the nurse take?
Discourage reminiscing about the past to minimize feelings of confusion.
Ask open-ended questions that encourage the client to express their feelings.
Use holiday decorations to provide orientation to the time of the year.
Encourage multiple family members to visit the client at the same time.
The Correct Answer is C
Choice A reason: Discouraging reminiscing about the past is not a helpful strategy for a client who has dementia and confusion. Reminiscing can stimulate memory, enhance mood, and promote social interaction.
Choice B reason: Asking open-ended questions that encourage the client to express their feelings is not appropriate for a client who has dementia and confusion. Open-ended questions can increase frustration and anxiety for the client who may have difficulty finding words or recalling events. The nurse should use simple, direct, and closed-ended questions instead.
Choice C reason: Using holiday decorations to provide orientation to the time of the year is a beneficial action for a client who has dementia and confusion. Holiday decorations can help the client recognize familiar cues and reduce disorientation.
Choice D reason: Encouraging multiple family members to visit the client at the same time is not advisable for a client who has dementia and confusion. Multiple visitors can overwhelm and agitate the client who may have trouble recognizing faces or voices. The nurse should limit the number of visitors and ensure they are calm and supportive.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.
Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.
Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.
Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.
Correct Answer is C
Explanation
Choice A: This is incorrect because hyperactive deep tendon reflexes are not associated with low serum calcium levels. Hyperactive deep tendon reflexes can indicate hypomagnesemia, hyperthyroidism, or spinal cord injury.
Choice B: This is incorrect because hypoactive bowel sounds are not associated with low serum calcium levels. Hypoactive bowel sounds can indicate ileus, peritonitis, or opioid use.
Choice C: This is correct because positive Chvostek's sign is associated with low serum calcium levels. Positive Chvostek's sign is a facial muscle spasm that occurs when tapping on the cheek near the ear. It indicates hypocalcemia, which can be caused by hemodialysis, renal failure, or parathyroid dysfunction.
Choice D: This is incorrect because lethargy is not associated with low serum calcium levels. Lethargy can indicate hypercalcemia, dehydration, hypoglycemia, or infection.
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