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.)
Reinforce orientation to time, place, and person.
Allow the client to choose among a variety of activities each day.
Give the client one simple direction at a time.
Establish eye contact when communicating with the client.
Refute the client's delusions using logic.
Correct Answer : A,C,D
A. Correct. Reinforcing orientation to time, place, and person helps ground the client in reality, even if their memory is impaired.
B. Incorrect. While it's important to provide the client with some choices, too many options can be overwhelming and confusing.
C. Correct. Providing one simple direction at a time helps prevent confusion and frustration for clients with dementia.
D. Correct. Establishing eye contact while communicating can enhance the client's focus and understanding.
E. Incorrect. It's generally not effective to try to refute a client's delusions using logic.
Redirecting or validating their feelings might be more appropriate.
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Related Questions
Correct Answer is D
Explanation
A. Incorrect. Restraints should be removed and repositioned, and the client's needs assessed at a frequency that follows institutional policies, which might not always be every 4 hours.
B. Incorrect. Restraints should be attached to the bed frame, not the side rails, to minimize the risk of injury.
C. Incorrect. PRN (as needed) restraint prescriptions should be avoided. Restraints should only be used based on specific criteria and under the guidance of a healthcare provider.
D. Correct. When using restraints, it's important to document the client's condition frequently to assess for any potential adverse effects or discomfort.
Correct Answer is B
Explanation
Choice A rationale:
A toddler running with a wide stance is a common behavior at this age and does not necessarily indicate developmental delay. Toddlers often develop a wide base of support as they learn to balance and walk more confidently.
Choice B rationale:
Falling when throwing a ball overhand requires coordination and motor skills. By the age of 24 months, most toddlers can throw a ball with some degree of accuracy. Inability to do so may indicate a developmental delay in motor skills, making choice B the correct answer.
Choice C rationale:
Referring to oneself by name is a typical language development milestone around the age of 24 months. It demonstrates a basic understanding of self-identity and language, indicating appropriate developmental progress. This choice does not suggest a delay.
Choice D rationale:
Going up stairs with two feet on each step is a gross motor skill that toddlers typically develop around 36 months of age. It requires balance and coordination. While it is advanced for a 24-month-old, it is not necessarily a sign of developmental delay. Therefore, this choice does not provide a clear indication of delay.
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