A nurse is caring for a client who has dementia and is experiencing disorientation. Which of the following actions should the nurse take?

Approach the client from the front.

Avoid having a structured schedule

Remove clocks from the room

Give detailed explanations

Answer and Explanation

The Correct Answer is A

A. Approach the client from the front: Approaching the client from the front is important to avoid startling them, especially if they are disoriented. It helps ensure they are aware of your presence and reduces confusion or anxiety.

B. Avoid having a structured schedule: A structured schedule is actually beneficial for clients with dementia. Routine helps provide stability and reduces anxiety by giving the client a sense of predictability and control.

C. Remove clocks from the room: Removing clocks is not recommended. Clocks can help orient the client to time and provide a sense of structure. It may be more helpful to use large clocks or calendars with clear time indicators.

D. Give detailed explanations: Giving detailed explanations may overwhelm the client, especially if they are disoriented. It’s more effective to provide simple, clear instructions and focus on one thing at a time.

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Correct Answer is B

Explanation

A. Minimize time spent gambling each week: While reducing time spent gambling can be helpful, the focus should be on addressing the underlying behaviors and emotions related to the gambling disorder. A more holistic approach is typically more effective.
B. Encourage the client to participate in a self-help group: Self-help groups, such as Gamblers Anonymous, provide valuable support for individuals with gambling disorders. These groups offer shared experiences and coping strategies, making them a crucial part of the treatment plan.
C. Ask the client why they are unable to stop gambling: Asking "why" may feel confrontational or non-supportive. Instead, the nurse should use therapeutic communication to explore the client’s thoughts and feelings in a non-judgmental way.
D. Obtain a prescription for memantine: Memantine is used to treat Alzheimer's disease and other cognitive disorders, not gambling disorder. Medications are not typically the primary treatment for gambling disorder; instead, therapy and behavioral interventions are applied.

A. Secure the client in bed by tightly tucking in sheets. B. Obtain a prescription to renew the restraint prescription every 48 hr. C. Document the interventions used before applying restraints. D. Delegate assistive personnel to check on the client regularly.

Correct Answer is C

Explanation

A. Secure the client in bed by tightly tucking in sheets: Tightly tucking sheets is not an appropriate use of restraints and may increase the risk of injury. Restraints should be applied according to proper guidelines, and they should allow the client to move as much as is safe.
B. Obtain a prescription to renew the restraint prescription every 48 hr: Restraint prescriptions must be renewed every 24 hours, not every 48 hours, to ensure ongoing assessment of the client's need for restraints.
C. Document the interventions used before applying restraints: It is important to document all interventions attempted before applying restraints. This includes any less restrictive measures that were tried and failed before restraints were applied, in line with best practices and legal requirements.
D. Delegate assistive personnel to check on the client regularly: While assistive personnel can help with monitoring, the nurse is ultimately responsible for ensuring the client is checked on regularly and for assessing the safety and well-being of the client in restraints.

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A nurse is caring for a client who has dementia and is experiencing disorientation. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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