A nurse is contributing to the plan of care for a client who has dementia. Which of the following interventions should the nurse recommend?

Discourage the client from reminiscing.

Encourage the client to eat meals in their room.

Limit directions for the client to three at a time.

Provide finger foods for the client at mealtimes.

Answer and Explanation

The Correct Answer is D

Care planning for a client with dementia focuses on maintaining safety, promoting independence, and supporting adequate nutrition while minimizing confusion and frustration. Clients with dementia often experience cognitive decline that affects memory, judgment, and executive functioning, making structured communication and simplified tasks essential. Interventions should enhance the client’s ability to participate in self-care while reducing environmental and cognitive demands. Nutrition is particularly important because these clients are at risk for poor intake due to forgetfulness or difficulty with utensils.

Rationale:
A. Discouraging reminiscence is not appropriate because recalling past experiences can provide comfort and promote engagement in clients with dementia. Reminiscence therapy is often used to stimulate memory and support emotional well-being. Preventing this activity may increase confusion and reduce therapeutic interaction.

B. Encouraging the client to eat meals in their room may increase isolation and reduce social stimulation, which can worsen cognitive decline and appetite. Mealtime in a structured communal setting often promotes better intake and orientation through routine. Social interaction can also enhance engagement and reduce agitation.

C. Limiting directions to three at a time is a useful communication strategy, but it does not directly address nutrition or mealtime safety needs in this question. While simplifying instructions is important, it is not the most appropriate intervention related specifically to improving eating ability and independence.

D. Providing finger foods supports independence and improves nutritional intake by allowing the client to eat without needing complex utensil use. In Dementia, clients often have difficulty with coordination and sequencing tasks, so finger foods make eating easier, safer, and more successful. This intervention directly enhances function and reduces the risk of malnutrition.

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Correct Answer is C

Explanation

Postoperative care following cataract surgery focuses on protecting the operative eye, preventing increased intraocular pressure, and promoting proper healing. Clients are taught to avoid activities that place strain on the eye or increase pressure within the surgical site. Nursing discharge teaching includes positioning precautions, eye protection measures, and recognition of complications such as infection or retinal detachment. Proper adherence to these instructions helps preserve vision and prevent surgical complications.

Rationale:
A. Removing the protective eye shield at bedtime is incorrect because the shield is usually worn while sleeping to protect the eye from accidental rubbing or pressure. The operative eye remains vulnerable during the early healing period, and nighttime protection helps prevent injury or disruption of the surgical repair following Cataract surgery.

B. Bending at the waist when picking up objects is contraindicated because this movement increases intraocular pressure. Increased pressure can place stress on the surgical site and increase the risk of hemorrhage or disruption of healing. Clients are instructed to squat or bend at the knees instead of bending forward.

C. Avoiding lying on the operative side is correct because direct pressure on the affected eye can impair healing and increase discomfort or intraocular pressure. Proper positioning helps protect the surgical site and reduces the risk of postoperative complications. Side-lying on the nonoperative side is generally preferred during recovery.

D. A brow headache persisting for several days is not expected and may indicate increased intraocular pressure or another postoperative complication. Clients should report severe eye pain or headache promptly because these findings can suggest complications requiring immediate evaluation. Normal postoperative discomfort is usually mild rather than severe or persistent.

A. Offer glucose water to the newborn every 1 to 2 hr. B. Obtain a blood glucose level from the newborn every 4 hr. C. Apply lotion to the newborn's skin every 2 hr. D. Reposition the newborn every 2 to 3 hr.

Correct Answer is D

Explanation

Phototherapy is used in newborns with hyperbilirubinemia to break down excess bilirubin in the skin through exposure to specific wavelengths of light. Effective management focuses on maximizing skin exposure, maintaining hydration, and preventing complications such as dehydration or skin breakdown. Nursing care includes frequent repositioning, eye protection, and monitoring elimination patterns. These interventions help ensure even light exposure and promote efficient bilirubin excretion.

Rationale:
A. Offering glucose water to the newborn every 1 to 2 hours is not recommended because breast milk or formula should remain the primary source of nutrition and hydration. Glucose water does not enhance bilirubin elimination and may interfere with adequate caloric intake. Maintaining normal feeding schedules supports stooling, which helps eliminate bilirubin.

B. Obtaining blood glucose levels every 4 hours is not routinely required for newborns receiving phototherapy unless there is a specific risk for hypoglycemia. Phototherapy primarily affects bilirubin metabolism rather than glucose regulation. Routine glucose monitoring is not a standard intervention in uncomplicated hyperbilirubinemia.

C. Applying lotion to the newborn’s skin every 2 hours is contraindicated because lotions can increase the risk of burns or interfere with the effectiveness of phototherapy. Oily substances may also intensify heat absorption and lead to skin irritation. Skin care during phototherapy should avoid topical products unless specifically prescribed.

D. Repositioning the newborn every 2 to 3 hours is correct because it ensures that all skin surfaces are exposed evenly to phototherapy light. This enhances the breakdown of bilirubin into water-soluble forms for excretion. In the management of Neonatal hyperbilirubinemia, frequent repositioning is a key nursing intervention to improve treatment effectiveness.

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Area assessed	Findings
Neurological	Drowsy but easy to arouse.
Vital Signs	Temperature 35.3° C (95.5° F) Heart rate 60/min Respiratory rate 16/min Blood pressure 90/60 mm Hg Oxygen saturation 94% (oxygen at 2 L/min via nasal cannula) Rates pain as 1 on 0/10 pain scale.
Integumentary	Skin cool and moist to touch.

A nurse is contributing to the plan of care for a client who has dementia. Which of the following interventions should the nurse recommend?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who is postoperative following cataract removal. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and is receiving phototherapy. Which of the following interventions should the nurse include?

Correct Answer is D

Explanation

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