A nurse is planning care for an older adult client who has dementia.
Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).

Allow the client to choose among a variety of activities each day.

Give the client one simple direction at a time.

Reinforce orientation to time, place, and person.

Establish eye contact when communicating with the client.

Answer and Explanation

Correct Answer : B,C,D

The nurse should give the client one simple direction at a time, reinforce orientation to time, place, and person, and establish eye contact when communicating with the client.

These interventions can help the client with dementia to understand and follow instructions, reduce confusion and anxiety, and enhance communication.

Choice A is wrong because allowing the client to choose among a variety of activities each day can overwhelm and frustrate the client with dementia.

The nurse should provide a structured and consistent daily routine for the client.

Choice E is wrong because refuting the client’s delusions using logic can increase the client’s agitation and distrust.

The nurse should use validation therapy to acknowledge the client’s feelings and emotions without arguing or correcting the client.

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Correct Answer is A

Explanation

The client has signs of dehydration and oliguria, which are low urine output and dark yellow urine. A fluid bolus can help restore the fluid balance and improve the renal perfusion. The normal urine output for an adult is 0.5-1.5 mL/kg/hr, and the client’s urine output is only 25 mL/hr, which is below the minimum acceptable level. Dark yellow urine can indicate a high concentration of waste products and a low intake of fluids.

Choice B is wrong because continuous bladder irrigation is used to prevent or treat blood clots in the bladder after surgery or injury, not to increase urine output.

Choice C is wrong because a urine specimen for culture and sensitivity is used to diagnose a urinary tract infection, which is not the most likely cause of the client’s low urine output.

The client does not have other symptoms of infection, such as fever, pain, or cloudy urine.

Choice D is wrong because clamping the catheter tubing for 30 min can cause urinary retention, bladder distension, and increased risk of infection.

It can also interfere with the accurate measurement of urine output.

A. “Your name cannot be removed once you are listed on the organ donor list.” B. “You must be at least 21 years of age to become an organ donor.” C. “I cannot be a witness for your consent to donate.” D. “Your desire to be an organ donor must be documented in writing.”

Correct Answer is D

Explanation

The correct answer is d. “Your desire to be an organ donor must be documented in writing.”

Rationale for Choice a:

Statement:“Your name cannot be removed once you are listed on the organ donor list.”
Rationale:This statement is incorrect.Individuals have the right to change their minds about organ donation at any time.They can have their names removed from the organ donor list by contacting the appropriate registry or organization.It's essential for nurses to provide accurate information to ensure informed consent and respect for patient autonomy.

Rationale for Choice b:

Statement:“You must be at least 21 years of age to become an organ donor.”
Rationale:This statement is also incorrect.The age requirement for organ donation varies by jurisdiction.In many places,individuals under 18 years of age can register as organ donors with parental consent.Nurses should be familiar with local regulations to provide accurate guidance.

Rationale for Choice c:

Statement:“I cannot be a witness for your consent to donate.”
Rationale:While it's true that nurses generally cannot act as witnesses for organ donation consent,the focus of the response should be on directing the client to the appropriate channels for documentation.Nurses can play a role in facilitating the process by providing information and resources to clients who express interest in organ donation.

Rationale for Choice d:

Statement:“Your desire to be an organ donor must be documented in writing.”
Rationale:This is the correct response.To ensure clarity and legal validity,organ donation preferences must be documented in writing.This documentation can be done through various means,such as registering with an organ donor registry,indicating preferences on a driver's license,or completing an advance directive.Nurses should emphasize the importance of written documentation to protect the client's wishes.

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System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states. "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says. "Why don't you just leave me? I am of no use.”

A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is postoperative following abdominal surgery and has an indwelling urinary catheter that is draining dark yellow urine at 25 mL/hr. Which of the following interventions should the nurse anticipate?

Correct Answer is A

Explanation

A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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A nurse is planning care for an older adult client who has dementia.
Which of the following interventions should the nurse include in the plan of care? (Select all that apply.).