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 []
Explanation
Rationale for correct condition
The client’s episodic wheezing, chest tightness, and nocturnal dry cough are classic signs of asthma. Use of accessory muscles and bilateral inspiratory and expiratory wheezing support airway obstruction typical in asthma. The absence of fever, crackles, or peripheral edema excludes infection or heart failure. The client’s history of GERD can exacerbate asthma symptoms via microaspiration and airway irritation. The rapid onset and progression over two days also favor asthma exacerbation over chronic conditions.
Rationale for correct actions
Administering a bronchodilator targets bronchospasm by relaxing airway smooth muscle via beta-2 adrenergic receptor stimulation, improving airflow and oxygenation. Bronchodilators rapidly reduce airway resistance, alleviating wheezing and dyspnea. Measuring peak expiratory flow quantifies airway obstruction severity, guiding treatment efficacy. Peak flow monitoring detects airflow limitation changes, enabling timely adjustments in therapy to prevent deterioration.
Rationale for correct parameters
Oxygen saturation reflects gas exchange efficiency, with normal range 95-100%; levels below 92% indicate hypoxemia requiring intervention. Monitoring saturation ensures oxygen therapy adequacy and early detection of respiratory failure. Pulmonary function tests (PFTs) objectively measure airway obstruction severity and reversibility, essential in asthma diagnosis and monitoring. PFTs detect changes in forced expiratory volume (FEV1) and forced vital capacity (FVC), indicating bronchoconstriction or improvement.
Rationale for incorrect conditions
COPD typically affects older smokers with chronic productive cough and progressive symptoms, unlike this nonsmoker with acute onset. Pneumonia presents with fever, productive cough, and focal lung findings such as crackles, absent here. Pulmonary edema involves fluid overload signs like peripheral edema and crackles, not observed in this client.
Rationale for incorrect actions
Teaching pursed-lip breathing is more beneficial in COPD to reduce air trapping, less effective in acute asthma. Antibiotics are not indicated without infection evidence, as this is a noninfectious exacerbation. Diuretics treat fluid overload in pulmonary edema, irrelevant in asthma.
Rationale for incorrect parameters
Temperature monitoring is not primary here, as no infection signs are present. Urine output assesses renal function or fluid status, not respiratory status. Weight monitoring is relevant in chronic heart failure management but not acute asthma.
Take home points
- asthma presents with episodic wheezing and nocturnal cough, often triggered by irritants
- bronchodilators and peak flow monitoring are critical in managing asthma exacerbations
- oxygen saturation and pulmonary function tests guide treatment effectiveness
- differentiate asthma from COPD, pneumonia, and pulmonary edema by clinical presentation and history
Correct Answer is A
Explanation
Choice A rationale
Active tuberculosis is primarily transmitted via airborne particles containing Mycobacterium tuberculosis. Therefore, isolating the client in a private room equipped with negative pressure ventilation is crucial. This system ensures that air from the room is exhausted directly outside or through a high-efficiency particulate air (HEPA) filter, preventing the dissemination of airborne pathogens to other areas and protecting healthcare workers and other clients from exposure.
Choice B rationale
Assigning a client with active tuberculosis to a room with clients requiring droplet precautions is inappropriate. Droplet precautions are for larger respiratory droplets that typically travel short distances, whereas tuberculosis involves smaller airborne nuclei that can remain suspended in the air and travel greater distances. This placement would significantly increase the risk of cross-contamination and disease transmission to other susceptible individuals within the healthcare environment.
Choice C rationale
While masks are essential for airborne precautions, routine use of gowns and gloves for staff and visitors is generally not required for tuberculosis unless direct contact with respiratory secretions or contaminated items is anticipated. The primary mode of transmission is airborne, making respiratory protection the paramount intervention. Over-gowning and gloving unnecessarily consume resources and do not significantly enhance protection against airborne transmission.
Choice D rationale
Modifying the protocol for donning and removing personal protective equipment (PPE) before entering or leaving the client's room is unsafe and increases the risk of contamination. Strict adherence to established PPE protocols, including proper hand hygiene and the correct sequence for donning and doffing, is critical to prevent self-contamination and the spread of pathogens. Any deviation from these protocols compromises safety and infection control efficacy.
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.