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 B
Explanation
Choice A rationale
Quadriplegia, or tetraplegia, involves paralysis affecting all four limbs and the torso, typically occurring with spinal cord injuries at the cervical level (C1-C8). A T2-T3 injury is below the cervical spine, so it would not result in quadriplegia.
Choice B rationale
Paraplegia involves paralysis that affects the lower half of the body, including both legs, and typically results from spinal cord injuries at the thoracic (T1-T12) or lumbar (L1-L5) levels. A T2-T3 injury would spare upper limb function but impair sensation and movement in the trunk and lower extremities.
Choice C rationale
Paresthesia refers to abnormal sensations such as tingling, prickling, or numbness, without actual paralysis. While paresthesia can be present with a spinal cord injury, it describes a sensory disturbance, not the type of motor disability, which is the primary focus of this question.
Choice D rationale
Hemiplegia is paralysis affecting one side of the body and is typically associated with brain injuries like stroke, rather than spinal cord injuries. Spinal cord injuries generally cause bilateral deficits below the level of the lesion.
Correct Answer is D
Explanation
Choice A rationale
The headache phase is the primary pain experience of a migraine, characterized by moderate to severe throbbing pain, often unilateral. This phase is associated with vasodilation of cerebral blood vessels and activation of trigeminal nerve pathways, leading to the debilitating pain and associated symptoms like photophobia and phonophobia.
Choice B rationale
The prodrome phase precedes the migraine headache by hours or days and involves subtle, non-specific symptoms such as fatigue, mood changes, neck stiffness, and food cravings. These symptoms reflect neurobiological changes in the brain that signal the impending migraine attack, providing an early warning to some individuals.
Choice C rationale
The postdrome phase, often called the "migraine hangover," occurs after the headache has resolved and can last for 24 to 48 hours. Symptoms include fatigue, difficulty concentrating, mood changes, and muscle soreness, indicating the brain's recovery process after the intense neuronal activity and inflammation of the headache phase.
Choice D rationale
The aura phase consists of focal neurological symptoms, typically visual (e.g., blind spots, flashing lights, zigzag lines), but can also include sensory (e.g., tingling, numbness) or motor disturbances. These transient symptoms precede or accompany the headache and are believed to be caused by cortical spreading depression, a wave of neuronal depolarization.
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