A nurse is planning care for an older adult client who has dementia and a nutritional deficit.
Which of the following actions should the nurse plan to take?
Serve the client soup in a mug.
Allow the client to cut up her own food.
Use colorful, patterned dishes to serve the client's meals.
Withhold fluids while the client is eating.
The Correct Answer is A
Choice A rationale
Serving soup in a mug promotes independence and is less likely to spill compared to a bowl, which is beneficial for a client with dementia who may have fine motor skill deficits. This action simplifies the eating process, reducing frustration and increasing the likelihood of successful nutrient intake. This is part of providing a safe and dignified environment for the patient.
Choice B rationale
Allowing a client with dementia to cut their own food can be dangerous due to impaired judgment, cognitive decline, and potential motor skill deficits, which increase the risk of injury. Providing pre-cut food is a safety measure that prevents accidental cuts or choking, ensuring the client's well-being and reducing caregiver burden.
Choice C rationale
Colorful, patterned dishes can cause perceptual distortions and visual confusion for a client with dementia due to changes in depth perception and visual-spatial processing. This can make it difficult for them to distinguish the food from the plate, leading to decreased food intake and increased frustration. It is better to use plain, solid-colored dishes.
Choice D rationale
Withholding fluids while a client is eating increases the risk of dehydration and can make swallowing solid foods more difficult, potentially leading to aspiration. It is important to encourage fluid intake throughout the meal to aid in chewing and swallowing, which supports hydration and nutritional status. *.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The shoulder harness straps should be positioned at or below the infant's shoulders when using a rear-facing car seat. This placement ensures that the crash forces are distributed across the strongest parts of the body and prevents the baby from sliding up out of the straps during an impact.
Choice B rationale
The retainer clip, or chest clip, should be placed at the level of the armpits, across the sternum. This position ensures that the shoulder straps remain securely on the shoulders and prevents the baby from being ejected from the harness in the event of a collision. Placing it on the abdomen can cause serious injury.
Choice C rationale
A 45-degree angle in a rear-facing car seat is a crucial safety measure. This reclined position ensures that the infant's airway remains open and unobstructed. It prevents the head from slumping forward, which could lead to positional asphyxiation, especially in newborns who lack strong neck control.
Choice D rationale
Current safety recommendations advise keeping a child rear-facing for as long as possible, until they reach the maximum height or weight limits of their car seat, which is typically well beyond one year of age. Turning the seat forward-facing at 1 year is no longer considered the safest practice. *.
Correct Answer is B
Explanation
Choice A rationale: Lubricating the catheter tip is an essential step to minimize trauma and discomfort during insertion. However, this is a technical preparation step that occurs after the sterile field has been established and the client has been draped.
Choice B rationale: Positioning the sterile drape is the priority action among the choices provided because it establishes the sterile field. Maintaining surgical asepsis is the most critical factor in preventing catheter-associated urinary tract infections (CAUTIs) during the procedure.
Choice C rationale: Cleansing the meatus with an antiseptic solution is the final step before actual insertion. This action must be performed after the sterile field is set up, the supplies are prepared, and the catheter is lubricated to ensure the area remains uncontaminated.
Choice D rationale: Attaching the prefilled syringe to the inflation hub is a preparation step to ensure the balloon can be inflated once the catheter is in the bladder. While important, it follows the establishment of the sterile environment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.