A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

Encourage frequent visits from friends.

Keep the over-the-bed light on.

Apply restraints to the upper extremities.

Play serene, soothing music.

Answer and Explanation

The Correct Answer is D

A. Encourage frequent visits from friends: While social interaction can be beneficial, it’s important to consider the individual’s needs and preferences. Overstimulation from too many visitors can cause anxiety or confusion, which can worsen cognitive symptoms.

B. Keep the over-the-bed light on: This may be helpful in preventing falls or confusion at night. However, it’s essential to avoid excessive lighting as it can disrupt the circadian rhythm, potentially leading to sleep disturbances. A dim nightlight is more appropriate.

C. Apply restraints to the upper extremities: Restraints should not be used as a first-line approach. They can increase confusion, anxiety, and the risk of injury. Non-restrictive interventions, such as proper positioning and a calm environment, should be prioritized.

D. Play serene, soothing music: Soothing music can be a helpful intervention to reduce anxiety, agitation, and confusion in clients with dementia. Music has been shown to have a calming effect, which can help the client feel more relaxed and at ease.

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Correct Answer is C

Explanation

A. ST segment: The ST segment represents the period between the end of ventricular depolarization and the beginning of ventricular repolarization. It does not reflect impulse conduction from the sinus node to the atrioventricular (AV) node.
B. QRS complex: The QRS complex represents ventricular depolarization and does not reflect impulse conduction through the atria or the AV node. It mainly reflects the electrical activity of the ventricles.
C. PR interval: The PR interval measures the time it takes for the electrical impulse to travel from the sinus node through the atria and AV node before reaching the ventricles. It is the most appropriate component for evaluating impulse conduction from the sinus node through the AV node.
D. PP interval: The PP interval measures the time between successive P waves, which corresponds to the time between atrial depolarizations. It does not specifically reflect conduction through the AV node.

A. Provide a low-residue diet. B. Administer a rectal suppository. C. Instruct the client to use a soft-bristled toothbrush. D. Encourage the client to use a safety razor when shaving.

Correct Answer is C

Explanation

A. Provide a low-residue diet: A low-residue diet is not directly related to managing thrombocytopenia. The priority for clients with thrombocytopenia is preventing bleeding, so dietary recommendations should focus on avoiding foods that can cause injury or irritation.

B. Administer a rectal suppository: Rectal suppositories should be avoided in clients with thrombocytopenia because they can cause trauma to the rectal mucosa and lead to bleeding due to the low platelet count.

C. Instruct the client to use a soft-bristled toothbrush: A soft-bristled toothbrush is important for clients with thrombocytopenia to prevent gum injury and bleeding. It minimizes the risk of oral bleeding while maintaining good oral hygiene.

D. Encourage the client to use a safety razor when shaving: A safety razor should not be recommended for clients with thrombocytopenia because it can cause cuts and bleeding. An electric razor is a safer alternative to minimize the risk of injury.

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A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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