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.

Answer and Explanation

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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Correct Answer is D

Explanation

A.Induration after a Mantoux test is a common response and does not necessarily require follow-up care.
B.A potassium level of 3.6 mEq/L is within the normal range (3.5-5.0 mEq/L).
C.Sodium phosphate is commonly used for bowel preparation before procedures like colonoscopy.
D.Correct. An INR of 1.8 for a client on warfarin is below the therapeutic range (usually 2.0- 3.0 for most indications), indicating that the client's blood may not be adequately anticoagulated. This requires follow-up to adjust the warfarin dose.

A. Schedule nursing staff training for infection control procedures. B. Identify possible precipitating factors related to the infections. C. Meet with providers to discuss measures to decrease the infections. D. Revise the current policy for catheter care.

Correct Answer is B

Explanation

A. While staff training is important, it may not address the immediate concern of identifying the cause of the infections.
B. Correct. Identifying the possible factors contributing to the infections is the first step in addressing the issue and preventing further infections.
C. Meeting with providers can be beneficial, but identifying the cause should come first before discussing measures.
D. Revising the policy for catheter care can be considered once the contributing factors are identified.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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