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.

Refute the client’s delusions using logic.

Answer and Explanation

Correct Answer : B,C,D

The correct answer is choice B, C, and 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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D. The client is oriented times three.

This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.

Choice A is wrong because the client withdraws from pain.

This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.

Choice B is wrong because the client is unable to obey commands.

This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.

Choice C is wrong because the client opens eyes to sound.

This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.

The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.

It consists of three tests: eye opening, verbal response, and motor response.

Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.

A. ECG results. B. Client's report of lack of food in home. C. client's report of lack of access to bank accounts. D. Clients avoidance of eye contact. E. Clients report of weight loss. F. Numerous bruises in various stages of healing.

Correct Answer is ["B","C","D","E","F"]

Explanation

Answer is B, C, D, E, F. These are the findings that suggest possible elder abuse or neglect.

B: Client’s report of lack of food in home. This may indicate neglect by the adult child who is supposed to provide adequate nutrition for the client.
C: Client’s report of lack of access to bank accounts. This may indicate financial abuse by the adult child who is controlling the client’s money without his permission.
D: Client’s avoidance of eye contact. This may indicate emotional abuse by the adult child who is intimidating or threatening the client.
E: Client’s report of weight loss. This may indicate neglect by the adult child who is not meeting the client’s basic needs or physical abuse by the adult child who is causing bodily harm to the client.
F: Numerous bruises in various stages of healing. This may indicate physical abuse by the adult child who is hitting or injuring the client.

A: ECG results. This is not a finding that suggests elder abuse or neglect. It is a diagnostic test that measures the electrical activity of the heart and can help detect cardiac problems. It does not provide information about the client’s social or emotional well-being.

Normal ranges for vital signs:.

Temperature: 36.1°C to 37.2°C (97°F to 99°F).
Heart rate: 60 to 100 beats per minute.
Blood pressure: less than 120/80 mm Hg.
Respiratory rate: 12 to 20 breaths per minute.
SpO2: 95% to 100% on room air. Table for BMI categories:

BMI	Weight Status
Below 18.5	Underweight
18.5 to 24.9	Normal
25.0 to 29.9	Overweight
30.0 and above	Obese

The client’s BMI is 18.3, which indicates he is underweight and may be malnourished or have a medical condition that causes weight loss.

View Question and Answer

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

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 in an emergency department is caring for a client following a motor-vehicle crash. The client’s Glasgow coma scale rating is 15. Which of the following findings should the nurse expect

Correct Answer is D

Explanation

Correct Answer is ["B","C","D","E","F"]

Explanation

A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take

A nurse in an emergency department is caring for a client. Exhibits Which of the following information provided by the client indicates improvement? Select all that apply.

A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching as an example of malpractice?

A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse’s priority?

A nurse is caring for a client who has a vented NG tube set to low intermittent suction and has vomited. Which of the following actions should the nurse perform first?

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy. The newborn is experiencing neonatal abstinence syndrome. Which of the following actions should the nurse include in the plan?

A nurse in an emergency department is caring for a client. Exhibits The nurse is providing teaching to the client about self-care. Select the 3 statements the nurse should include in the teaching.

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.).