D.B. is admitted to a long-term care facility. He has impaired memory related to effects of dementia. An appropriate nursing intervention for him is to:

Let him know what behavior is socially appropriate

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

Assist him with all self-care to maintain self-esteem

Answer and Explanation

The Correct Answer is B

A. Let him know what behavior is socially appropriate. While it is important to gently redirect inappropriate behavior, individuals with dementia may not retain this information due to impaired memory and cognitive decline. This approach is not as effective as maintaining familiar routines.
B. Maintain familiar routines of sleep, meals, drug administration, and activities. Consistent routines help reduce confusion and anxiety in individuals with dementia. Predictable schedules reinforce a sense of security, making it easier for the patient to remember daily activities and participate in self-care. Disruptions to routine can lead to increased agitation and disorientation.
C. Promote orientation at every encounter with the patient by asking the day, time, and place. While gentle reorientation can be helpful, repeatedly questioning the patient about time and place may lead to frustration, agitation, or embarrassment. A better approach is to use environmental cues (e.g., clocks, calendars, labeled rooms) and offer reassurance.
D. Assist him with all self-care to maintain self-esteem. Encouraging independence in self-care to the extent possible is crucial for maintaining dignity and self-esteem. Providing total assistance when unnecessary can lead to learned helplessness and increased dependence. Instead, the nurse should offer support only when needed while encouraging the patient to perform tasks independently.

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Correct Answer is B

Explanation

A. "I know that I cannot switch brands of this medication." Phenytoin has a narrow therapeutic index, meaning small changes in drug levels can lead to toxicity or treatment failure. Different brands and formulations may have variations in absorption, so clients should stay on the same brand unless directed otherwise by their provider.
B. "I'll be glad when I can stop taking this medicine." Phenytoin is a long-term medication for seizure control and should not be stopped abruptly, as this can lead to recurrent seizures or status epilepticus. Most clients with epilepsy require lifelong therapy, making this statement incorrect and indicating a need for further teaching.
C. "I have made an appointment to see my dentist next week." Phenytoin can cause gingival hyperplasia (gum overgrowth), a common side effect that can be minimized with good oral hygiene and regular dental visits. This statement indicates that the client understands the importance of dental care while taking phenytoin.
D. "I will notify my doctor before taking any other medications." Phenytoin has many drug interactions because it induces liver enzymes, affecting the metabolism of other medications. Clients should always consult their provider before taking new prescriptions, over-the-counter drugs, or supplements to avoid interactions that could alter drug effectiveness or increase toxicity risk.

A. Provide a nonskid mat to alleviate plate movement. B. Remind the client to look for food on the left side of the tray. C. Encourage the use of the wide grip utensils. D. Encourage the client to use his right hand when feeding himself.

Correct Answer is B

Explanation

A: "Provide a non-skid mat to alleviate plate movement." Using a non-skid mat can help prevent the plate from moving, but it does not address the specific issue of homonymous hemianopsia, which affects the client's visual field and ability to see food on one side.
B: "Remind the client to look for food on the left side of the tray." This strategy directly addresses the challenge posed by homonymous hemianopsia, which results in the loss of vision in half of the visual field. Reminding the client to scan the left side of the tray helps ensure that they can locate and eat their food more effectively.
C: "Encourage the use of the wide grip utensils." While using wide grip utensils may assist with grip and dexterity, it does not specifically address the visual field deficit caused by homonymous hemianopsia. This option does not improve the client’s ability to see the food they need to eat.
D: "Encourage the client to use his right hand when feeding himself." Using the right hand may not be beneficial for the client. If the client has right-sided stroke effects, using the right hand could be difficult due to weakness or hemiparesis. Promoting the use of the unaffected side is usually more effective in fostering independence in eating.

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D.B. is admitted to a long-term care facility. He has impaired memory related to effects of dementia. An appropriate nursing intervention for him is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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