A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

"Give the client several choices of foods for meals."

"Label the door to the bathroom with a symbol."

"Increase environmental stimuli."

"Avoid making eye contact with the client."

Answer and Explanation

The Correct Answer is B

Home management of a client with dementia focuses on maintaining safety, promoting orientation, and reducing confusion caused by progressive cognitive decline associated with Dementia. Clients often experience impaired memory, disorientation, and difficulty recognizing familiar environments. Care strategies emphasize simplification of the environment, use of visual cues, and consistent routines to support remaining cognitive function. Nursing education for caregivers should prioritize interventions that enhance orientation and reduce environmental stressors.

Rationale:
A. Giving the client several food choices increases cognitive burden and may lead to confusion or frustration. Clients with dementia benefit from simplified decision-making to reduce anxiety and improve cooperation. Limiting choices supports independence while preventing overwhelming stimuli.

B. Labeling the bathroom door with a symbol provides clear visual cues that support orientation and independence in activities of daily living. In Dementia, visual-spatial recognition is often impaired, and symbolic cues help compensate for memory deficits. This intervention promotes safety and reduces incontinence-related accidents by facilitating timely bathroom access.

C. Increasing environmental stimuli is inappropriate because excessive noise, clutter, or activity can worsen confusion and agitation in clients with dementia. A calm, structured, and predictable environment helps reduce sensory overload. Minimizing unnecessary stimuli supports better cognitive functioning and behavioral stability.

D. Avoiding eye contact is incorrect because eye contact helps establish trust, communication, and reassurance. Clients with dementia rely heavily on nonverbal cues to interpret interactions. Maintaining appropriate eye contact supports engagement and reduces feelings of isolation or fear.

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Correct Answer is C

Explanation

Postoperative care following cataract surgery focuses on protecting the operative eye, preventing increased intraocular pressure, and promoting proper healing. Clients are taught to avoid activities that place strain on the eye or increase pressure within the surgical site. Nursing discharge teaching includes positioning precautions, eye protection measures, and recognition of complications such as infection or retinal detachment. Proper adherence to these instructions helps preserve vision and prevent surgical complications.

Rationale:
A. Removing the protective eye shield at bedtime is incorrect because the shield is usually worn while sleeping to protect the eye from accidental rubbing or pressure. The operative eye remains vulnerable during the early healing period, and nighttime protection helps prevent injury or disruption of the surgical repair following Cataract surgery.

B. Bending at the waist when picking up objects is contraindicated because this movement increases intraocular pressure. Increased pressure can place stress on the surgical site and increase the risk of hemorrhage or disruption of healing. Clients are instructed to squat or bend at the knees instead of bending forward.

C. Avoiding lying on the operative side is correct because direct pressure on the affected eye can impair healing and increase discomfort or intraocular pressure. Proper positioning helps protect the surgical site and reduces the risk of postoperative complications. Side-lying on the nonoperative side is generally preferred during recovery.

D. A brow headache persisting for several days is not expected and may indicate increased intraocular pressure or another postoperative complication. Clients should report severe eye pain or headache promptly because these findings can suggest complications requiring immediate evaluation. Normal postoperative discomfort is usually mild rather than severe or persistent.

A. Encourage the client to use the overbed trapeze. B. Maintain abduction of the client's residual limb with a pillow. C. Caution the client to avoid a prone position while in bed. D. Keep a loose, absorbent dressing over the client's surgical site.

Correct Answer is A

Explanation

Postoperative care following an above-the-knee amputation focuses on pain control, prevention of contractures, wound healing, and early mobility to promote functional independence. Early rehabilitation is essential to prepare the residual limb for prosthetic fitting and long-term mobility. Interventions that enhance upper body strength and facilitate repositioning are key components of recovery. Proper positioning and wound care are also important to prevent complications such as contractures and infection in clients recovering from an Above-the-knee amputation.

Rationale:
A. Encouraging the use of an overbed trapeze promotes upper body strength, independence in repositioning, and early mobility. It allows the client to assist in turning, transferring, and performing activities of daily living, which are critical for rehabilitation after amputation. Strengthening the upper extremities supports future use of assistive devices and prosthetic training.

B. Maintaining abduction of the residual limb with a pillow is incorrect because it increases the risk of hip flexion contractures. Prolonged flexion or improper positioning can interfere with prosthetic fitting and long-term mobility. The residual limb should be positioned in neutral alignment rather than abducted with a pillow.

C. Cautioning the client to avoid a prone position is incorrect because prone positioning is actually recommended to prevent hip flexion contractures. Regular prone positioning helps maintain hip extension and preserves proper alignment of the residual limb. Avoiding this position may increase the risk of long-term mobility limitations.

D. Keeping a loose, absorbent dressing over the surgical site is appropriate for wound care but does not directly promote independence or mobility. While proper dressing management is essential for infection prevention and drainage control, it does not contribute significantly to functional rehabilitation goals compared to mobility-enhancing interventions.

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A nurse is reinforcing teaching about home management with the partner of a client who has dementia. Which of the following instructions should the nurse include in the teaching?

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Correct Answer is C

Explanation

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