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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Correct. The priority is to assess the client for any adverse effects of the medication, such as a drop in blood pressure, which can result in orthostatic hypotension.
B. Incorrect. Nasal congestion is not typically associated with an overdose of valsartan.
C. Incorrect. While obtaining laboratory results might be necessary, it is not the priority action in this situation.
D. Incorrect. Monitoring urine output is important, but assessing for potential complications related to the overdose takes precedence.
Correct Answer is D
Explanation
As explained, holding the bottle directly over the sterile field can result in contamination. It's crucial to pour the solution from above or to the side of the sterile field, making sure the bottle doesn't touch the field or anything in the field. This minimizes the risk of contaminating the sterile setup.
If solution is spilled on the sterile field, that area is contaminated, and you cannot make it sterile again by covering it with gauze. The correct approach would be to discard the contaminated items and set up a new sterile field.
While it's important not to touch the label side of the bottle, this option doesn't address the action of placing the cap. The most important part of pouring a sterile solution is ensuring the cap stays sterile, which is what option D addresses.
When performing a sterile procedure, after removing the cap from a sterile bottle, the cap should be placed sterile-side up on a clean surface or a sterile field. This is because the sterile side of the cap should not touch any non-sterile surfaces, and placing it sterile-side up ensures it stays sterile.
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