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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

The priority action in this situation is to set behavioral limits for the client. This is important for maintaining a safe environment for the client, other staff members, and other clients. By setting limits, the nurse establishes clear boundaries and expectations for behavior, helping to prevent the escalation of aggression or violence.
Let's examine why the other choices are incorrect:

A. Exploring the truth of the client's statements: While it is important to listen to and validate the client's concerns, in this particular situation, where the client is becoming agitated and confrontational, addressing the truth of their statements is not the priority. The immediate concern is ensuring safety and de-escalating the situation.

B. Establishing a therapeutic nurse-client relationship: Developing a therapeutic relationship is crucial for providing effective care, but it may not be the immediate priority when a client is displaying aggressive or violent behavior. Safety takes precedence in such situations, and setting behavioral limits is necessary before establishing a therapeutic relationship can effectively occur.

D. Showing the client around the unit and introducing her to other clients: This action is inappropriate during an agitated and confrontational episode. It is important to first
address the client's behavior and ensure the safety of all individuals involved before engaging in social activities or introductions.

A. "Why do you think the copper helps with your arthritis?" B. "I think you should rely more on your medication therapy than on your bracelet." C. "Yes, I understand that you feel better wearing your bracelet." D. "Believing objects have powers to make you feel better has no scientific basis."

Correct Answer is C

Explanation

This response acknowledges the client's subjective experience and validates their belief that the bracelet provides pain relief. It shows empathy and respect for the client's perspective without dismissing or challenging their belief.

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

A. "Why do you think the copper helps with your arthritis?" This response may come across as questioning or doubting the client's belief, which can be invalidating and may hinder the

nurse-client relationship.

B. "I think you should rely more on your medication therapy than on your bracelet." While it is important to emphasize evidence-based medical treatments, this response may be perceived as dismissive or confrontational. It is essential to maintain a supportive and collaborative approach.

D. "Believing objects have powers to make you feel better has no scientific basis." Although this statement is true in terms of scientific evidence, it may undermine the client's beliefs and create a sense of defensiveness or disagreement. It is more effective to maintain a respectful and non-judgmental attitude.

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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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Explanation

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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.