A nurse working in a long-term care facility is admitting a client who has dementia.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Regression is a defense mechanism that involves reverting to an earlier stage of development or behaving in a way that is characteristic of an earlier developmental level in response to stress or anxiety. It is a way for individuals to cope with overwhelming emotions or situations by retreating to a previous, more comfortable state.
In the scenario described, the client's behavior of consistently being late for appointments and ignoring household chores while expressing the need to be taken care of indicates a regressive response to stress. By relying on others to take care of their responsibilities, the client is seeking a sense of security and support, similar to how they may have relied on others in the past, such as during childhood.
Inc
A- Repression involves the unconscious blocking of unacceptable thoughts or impulses from conscious awareness.
B- Introjection is the internalization of values or qualities of another person or group.
C- Dissociation is a defense mechanism that involves detaching oneself from reality or the present moment to avoid emotional distress.
Correct Answer is C
Explanation
Group therapy is a valuable treatment method in mental health settings that offers several benefits. The statement "It establishes a situation where the client can relate to others and share perceptions" highlights one of the primary advantages of group therapy. In a group therapy setting, individuals with similar mental health issues come together to share their experiences, challenges, and perspectives. This process allows clients to realize that they are not alone in their struggles and fosters a sense of belonging and understanding. It can provide comfort, validation, and support as participants gain insight into their own thoughts and feelings through interactions with others.
Incorrect:
A. "It is economical since one staff member can treat many clients at once." While group therapy can be cost-effective in terms of staff resources, its primary goal is not solely based on economic considerations. The focus is on providing a therapeutic environment that promotes growth, support, and interpersonal learning for participants.
B. "It provides a forum to reinforce client teaching regarding medication administration." Although group therapy sessions may occasionally touch upon topics related to medication management, the main purpose of group therapy is not to provide medication education or reinforcement. Individual counseling or psychoeducation sessions are typically more appropriate for that specific purpose.
D. "It enables clients to see that other individuals have mental health issues." While it is true that group therapy allows individuals to witness the experiences of others with mental health issues, the purpose is not limited to simply observing that others have similar struggles. The primary goal is to create a safe space for participants to actively engage, share, and explore their own experiences in a supportive and therapeutic group setting. The focus is on personal growth, insight, and development.
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