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
Pulse oximetry measures the oxygen saturation of hemoglobin in peripheral blood, which is an indirect and less accurate measure of oxygen concentration in the blood, especially in patients with respiratory compromise or poor peripheral perfusion. It is non-invasive and provides an estimate (normal range 95-100%).
Choice B rationale
A capillary blood sample, typically obtained from a fingertip, provides information on blood glucose or lactate, but it is not the most accurate method for assessing arterial oxygen concentration due to its mixed venous and arterial components and potential for air exposure.
Choice C rationale
Assessment of the patient's nail beds provides a visual, qualitative assessment of peripheral perfusion and oxygenation (e.g., cyanosis), but it is subjective and not a precise or scientific measurement of the actual oxygen concentration in the blood.
Choice D rationale
An arterial blood gas (ABG) study directly measures the partial pressure of oxygen in arterial blood ($PaO_2$), along with carbon dioxide, pH, and bicarbonate. This provides the most accurate and precise assessment of oxygenation status and acid-base balance in the patient's blood. Normal $PaO_2$ is 80-100 mmHg.
Correct Answer is C
Explanation
Choice A rationale
Restricting fluid intake in clients with COPD can lead to thickened secretions, making them more difficult to expectorate. Adequate hydration (typically 2-3 liters per day unless contraindicated) is crucial for maintaining thin, mobile respiratory secretions, which facilitates mucociliary clearance and reduces the risk of mucus plugging and subsequent exacerbations. This restriction would hinder respiratory hygiene.
Choice B rationale
Clients with COPD often experience increased metabolic demands due to the effort of breathing and may be at risk for malnutrition and muscle wasting. A low-protein diet would be detrimental, as protein is essential for maintaining respiratory muscle strength, tissue repair, and immune function. A high-protein, high-calorie diet is often recommended to support their nutritional status and overall health.
Choice C rationale
Pursed-lip breathing is a technique that helps clients with COPD by increasing intrabronchial pressure, which prevents premature airway collapse during exhalation, particularly in those with emphysema. This prolongs exhalation, improves gas exchange by allowing more complete emptying of the lungs, reduces air trapping, and can alleviate dyspnea, improving ventilatory efficiency.
Choice D rationale
For clients with COPD, exercising and engaging in activities during early-morning hours can be problematic. This is often the time when respiratory secretions are most abundant and tenacious due to nocturnal accumulation. Engaging in strenuous activity then can exacerbate dyspnea and increase the risk of bronchospasm or fatigue, making later parts of the day often more suitable for activity.
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