A patient is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia.
An appropriate nursing intervention for him is to?
Let him know what behavior is socially appropriate.
Assist him with all self-care to maintain self-esteem.
Maintain familiar routines of sleep, meals, drug administration, and activities.
Promote orientation at every encounter with the patient by asking the day, time, and place.
The Correct Answer is C
Choice A rationale
While socially appropriate behavior is important, directly confronting a patient with impaired memory due to dementia about their behavior can cause agitation and distress. Their cognitive impairment prevents them from fully understanding and modifying their actions, so this approach is not scientifically effective in this neurological condition. The focus should be on creating a supportive environment.
Choice B rationale
Assisting with all self-care can diminish a patient's autonomy and sense of accomplishment, potentially leading to increased dependence and reduced self-esteem. Promoting independence in activities of daily living, even with supervision or partial assistance, stimulates cognitive function and preserves dignity in individuals with dementia.
Choice C rationale
Maintaining familiar routines provides a structured and predictable environment, which reduces anxiety and confusion in patients with dementia. This consistency helps to preserve residual cognitive function and can improve sleep patterns, appetite, and cooperation with medication administration by minimizing cognitive load and unexpected changes.
Choice D rationale
While orientation is important, repetitive questioning about day, time, and place can be frustrating and upsetting for a patient with severe memory impairment. This approach highlights their deficits and can lead to agitation. Environmental cues and gentle reorientation as needed are more therapeutic than constant questioning.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While obtaining the client's heart rate is important for a complete assessment, it is not the immediate priority in managing autonomic dysreflexia. Bradycardia often accompanies the hypertension, but addressing the physiological trigger and reducing the severe blood pressure elevation is more critical to prevent life-threatening complications.
Choice B rationale
Assessing the client for bladder distention is crucial, as it is a common precipitating factor for autonomic dysreflexia. However, the initial action should focus on rapidly reducing the dangerously high blood pressure to prevent complications like stroke, which can be achieved through immediate positional changes.
Choice C rationale
Administering a nitrate antihypertensive is a pharmacological intervention that might be necessary, but it is not the first action. The immediate priority is to non-pharmacologically reduce the blood pressure and search for the underlying noxious stimulus. Pharmacological agents are used if initial measures are insufficient.
Choice D rationale
Placing the client in a high-Fowler's position is the most immediate and critical first action. This position helps to reduce blood pressure by promoting venous pooling in the lower extremities, thereby decreasing venous return to the heart and reducing cerebral blood flow, mitigating the risk of intracranial hemorrhage from severe hypertension.
Correct Answer is C
Explanation
Choice A rationale
Having the client identify specific smells assesses the function of the olfactory nerve, which is Cranial Nerve I. This nerve is responsible for the sense of smell and is tested independently of the facial nerve, which governs motor functions of the face and taste sensation.
Choice B rationale
Checking the client's visual acuity using a Snellen chart assesses the optic nerve, Cranial Nerve II. This nerve transmits visual information from the retina to the brain. Its function is distinct from that of Cranial Nerve VII, which controls facial muscle movements and taste.
Choice C rationale
Observing for facial symmetry while the client smiles directly assesses the motor function of Cranial Nerve VII, the facial nerve. This nerve innervates the muscles of facial expression. Asymmetry or weakness indicates potential damage or dysfunction of this specific cranial nerve. Normal range includes symmetrical movement.
Choice D rationale
Whispering in one of the client's ears while occluding the other assesses the vestibulocochlear nerve, Cranial Nerve VIII. This nerve is responsible for hearing and balance. It is not involved in controlling facial expressions or taste sensation, which are functions of Cranial Nerve VII.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.