An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

Reorient the client while performing assessment.

Lower the lighting in the client's room.

Switch to a familiar topic after acknowledging client's feelings.

Remind the client that his spouse is deceased.

Explain the rehabilitation regimen to the client.

Answer and Explanation

Correct Answer : B,C

A. Reorient the client while performing assessment: Reorienting a client with acute dementia during periods of distress can increase confusion and agitation. Forcing orientation is often counterproductive and may escalate anxiety.

B. Lower the lighting in the client's room: Reducing harsh lighting can help decrease overstimulation and agitation, creating a calmer environment for a client experiencing acute confusion or distress.

C. Switch to a familiar topic after acknowledging client's feelings: Validating the client’s emotions and then gently redirecting to familiar topics can reduce anxiety, provide comfort, and improve cooperation without causing confrontation.

D. Remind the client that his spouse is deceased: Confronting the client with reality in a distressed state can increase agitation, fear, and confusion. Reality orientation should be approached cautiously, if at all, during acute episodes.

E. Explain the rehabilitation regimen to the client: While education about care is generally important, a client in acute dementia may not be able to process detailed explanations. This intervention does not address immediate emotional distress or safety.

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Correct Answer is B

Explanation

A. Before going to bed: Bedtime glucose checks may be recommended for some clients, especially those on insulin, but this timing is individualized. It is not universally required for every client with diabetes.

B. During acute illness: Any client with diabetes, regardless of age or type, should monitor glucose closely during acute illness. Illness can cause stress-induced hyperglycemia or unpredictable fluctuations, requiring more frequent testing to guide management.

C. Prior to exercising: Checking glucose before exercise is important for clients at risk of hypoglycemia, especially those using insulin or certain oral agents. However, this is not necessary for all clients, particularly those with type 2 diabetes controlled by diet alone.

D. Immediately after meals: Postprandial monitoring is useful in some cases to evaluate mealtime insulin effectiveness or dietary impact, but it is not universally recommended for every diabetic client. Its use depends on individualized treatment plans.

A. Calculate the intake and output. B. Assess pulse rate. C. Monitor the temperature. D. Checking for orthostatic hypotension. E. Obtain a daily weight.

Correct Answer is ["A","E"]

Explanation

A. Calculate the intake and output: Measuring intake and output directly reflects fluid balance, making it one of the most reliable ways to determine if fluid restriction and diuretics are effective. Tracking fluid intake compared to urine output helps assess reduction in fluid overload.

B. Assess pulse rate: While monitoring pulse rate is part of routine assessment, it does not provide a clear picture of whether fluid overload is improving. Changes in pulse may occur with dehydration, arrhythmias, or other conditions, but it is not a primary measure of fluid balance.

C. Monitor the temperature: Body temperature is important for identifying infection or inflammation but does not indicate fluid status. Monitoring temperature would not help evaluate whether fluid restriction and diuretic therapy are relieving fluid overload.

D. Checking for orthostatic hypotension: Orthostatic changes can suggest hypovolemia or dehydration but are less useful for measuring the gradual effectiveness of fluid restriction. They may be monitored if over-diuresis is suspected, but they are not the best evaluation tool.

E. Obtain a daily weight: Daily weight is one of the most accurate indicators of fluid balance. A decrease in weight reflects effective removal of excess fluid, as even small weight changes can indicate significant fluid gain or loss in the body.

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An older male client who is admitted to a rehabilitation facility manifests signs of acute dementia. The nurse observes the client repeatedly calling out for his deceased spouse to come and get him. Which intervention(s) should the nurse implement? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?

Correct Answer is B

Explanation

A client with fluid overload receives a prescription for fluid restriction of 1 liter/day and a diuretic. Which action(s) should the nurse perform to best evaluate the effectiveness of the treatment? Select all that apply.

Correct Answer is ["A","E"]

Explanation

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