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A nurse working in a long-term care facility is admitting a client who has dementia.

Exhibits

Which of the following interventions should the nurse include in the plan of care?
Select all that apply.

Obtain client's weight weekly.

Offer the client finger foods for meals.

Speak loudly when addressing the client.

Give long task at a time to the client

Turn the clients TV on at night when they are unable to sleep.

Encourage the client to take deep breaths when feeling agitated.

Assess client's memory every shift.

Answer and Explanation

Correct Answer : A,B,F,G

From the given information, the nurse should include the following interventions in the plan of care for the client with dementia:
●   Obtain client's weight weekly: Regular weight monitoring helps assess the client's nutritional status and detect any significant changes that may require intervention.
●   Offer the client finger foods for meals: Finger foods can be easier for the client to handle and consume independently, promoting independence and self-feeding.
●   Encourage the client to take deep breaths when feeling agitated: Deep breathing exercises can help the client manage their agitation and promote relaxation.
●   Assess client's memory every shift: Regular assessment of the client's memory allows for monitoring any changes or decline, which helps in planning appropriate interventions and providing necessary support.
The following interventions should be avoided:

●   Speak loudly when addressing the client: Speaking loudly may cause confusion or agitation in the client. Instead, it is recommended to use a calm and reassuring tone of voice.
●   Give long tasks at a time to the client: Clients with dementia often have difficulty with concentration and memory. Providing long tasks may overwhelm them and contribute to their frustration. Breaking tasks into smaller, manageable steps is more appropriate.

●   Turn the client's TV on at night when they are unable to sleep: It is generally recommended to create a quiet and calming environment for sleep. The TV may interfere with the client's sleep and contribute to increased agitation or confusion.

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Correct Answer is A

Explanation

Establishing a consistent bedtime routine and sleep schedule can promote better sleep hygiene and help regulate the client's sleep-wake cycle. By getting the client ready for sleep at the same time each night, the nurse helps create a predictable and calming routine that signals to the body that it is time to sleep.

Incorrect:

B. Move the client to a room next to the open nurses' station: This measure may increase noise and disturbances, which can further disrupt the client's sleep. Providing a quiet and peaceful environment is generally more conducive to restful sleep.

C. Encourage the client to take a 1-hour nap each afternoon: While short daytime naps can be beneficial for some individuals, they may interfere with the client's ability to fall asleep or stay asleep at night. It is generally recommended to limit daytime napping, especially if the client is having trouble sleeping at night.

D. Play the client's favorite music in the room while the client is sleeping: While some individuals find soothing music helpful for relaxation and sleep, it is essential to consider the client's preferences. Not everyone finds music helpful for sleep, and it is important to respect the client's preferences and individual needs. Some clients may find silence or white noise more conducive to sleep.

A. Projection B. Dissociation C. Repression D. Sublimation

Correct Answer is B

Explanation

Dissociation is a defense mechanism in which a person disconnects from their thoughts, feelings, memories, or sense of identity as a way to cope with overwhelming or traumatic experiences. In this case, the client's inability to remember anything that happened after seeing the suspects in the stabbing is a form of dissociation. It is a way for the client to psychologically distance themselves from the traumatic event and protect themselves from the emotional distress associated with it.

A- Projection is a defense mechanism where an individual attributes their own undesirable thoughts, feelings, or impulses onto someone else.

C- Repression is a defense mechanism where disturbing or unacceptable thoughts, memories, or feelings are pushed into the unconscious mind.

D- Sublimation is a defense mechanism where unacceptable impulses or emotions are redirected into socially acceptable activities.

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A nurse working in a long-term care facility is admitting a client who has dementia. Exhibits Which of the following interventions should the nurse include in the plan of care? Select all that apply.

Nursing Test Bank

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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A nurse working in a long-term care facility is admitting a client who has dementia.

Exhibits

Which of the following interventions should the nurse include in the plan of care?
Select all that apply.