A nurse is assisting with the care of a client who has dementia.
Which of the following actions should the nurse take?.

. Make a personal introduction to the client at each interaction.

Give the client a list of foods to choose from for dinner.

Repeat orientation questions until the client gives a correct response.

Provide the client with a dark environment for sleeping.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Making a personal introduction to the client at each interaction is a recommended approach for clients with dementia. It helps to orient the client and establish a connection, which can reduce confusion and anxiety.

Choice B rationale:

Giving a client with dementia a list of foods to choose from for dinner may be overwhelming due to impaired decision-making abilities.

Choice C rationale:

Choice D rationale:

Providing a dark environment for sleeping can be disorienting for a client with dementia. A low level of light can help the client maintain orientation to their surroundings.

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Correct Answer is B

Explanation

Choice A rationale:

Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.

Choice B rationale:

Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.

Choice C rationale:

The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.

Choice D rationale:

Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.

A. Timeout B. Restraint. C. Diversion. D. Therapeutic hold.

Correct Answer is A

Explanation

Choice A rationale:

A timeout is a de-escalation technique where the client is allowed to spend time alone in a safe environment to regain control.

Choice B rationale:

Restraint is not a de-escalation technique. It is a last resort measure used when other methods have failed and the client is a danger to themselves or others.

Choice C rationale:

Diversion is a technique used to distract the client from a stressful situation, not a de-escalation technique.

Choice D rationale:

A therapeutic hold is a type of physical restraint, not a de-escalation technique.

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A nurse is assisting with the care of a client who has dementia. Which of the following actions should the nurse take?.

A nurse is assisting with the care of a client who has dementia.
Which of the following actions should the nurse take?.