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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 C

Explanation

This response acknowledges the client's need for assistance while redirecting the focus towards exploring alternative solutions. It demonstrates the nurse's willingness to help and initiates a collaborative problem-solving approach. By engaging in a discussion about available resources, the nurse can help the client explore options such as home delivery services, community support programs, or involving family and friends in assisting with grocery shopping.

Let's review the other options and explain why they are not the most appropriate responses:

A. "I won't be able to shop for you today because I have to get home to my family." This response lacks empathy and doesn't address the client's needs. It is important for the nurse to prioritize the client's well-being and explore appropriate solutions rather than providing personal reasons for not being able to assist.

B. "What I think you should do is wait for the days when you feel better and do your grocery shopping then." This response overlooks the client's current limitations and implies that the client should solely rely on their own abilities, which may not be feasible or practical for the client.

D. "I would be happy to do whatever I can to help you." While this response conveys the nurse's willingness to assist, it is important to remember that shopping and performing personal errands are typically outside the scope of a home care nurse's responsibilities. It is more appropriate to explore other resources and options to address the client's needs effectively.

A. The client trains his mind to relax by using deep inner resources. B. The client learns the source of his stress by writing down daily events. C. The client imagines being in a quiet, relaxing environment. D. The client learns to change negative thoughts into positive statements.

Correct Answer is D

Explanation

Effective use of cognitive reframing involves shifting negative thoughts or perspectives into more positive and realistic ones. By learning to change negative thoughts into positive statements, the client is actively engaging in cognitive reframing techniques. This process allows the client to challenge and reframe negative thinking patterns, which can help reduce stress and promote a more positive outlook.

Incorrect:

A. Training the mind to relax by using deep inner resources is a helpful technique for relaxation and stress reduction. However, it does not specifically involve cognitive reframing, which focuses on modifying thought patterns and perspectives.

B. Learning the source of stress by writing down daily events can be a useful tool for

self-awareness and understanding triggers. While it may contribute to stress management, it does not directly involve cognitive reframing.

C. Imagining being in a quiet, relaxing environment can be a relaxation technique that helps reduce stress. However, it is not specifically related to cognitive reframing, which centers on changing thought patterns.

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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

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A nurse is helping a client relieve stress through cognitive reframing. Which of the following actions by the client demonstrates effective use of cognitive reframing?

Correct Answer is D

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.