The nurse is providing care for an elderly client who has dementia. Interventions used would include: (SELECT ALL THAT APPLY)

modifying the environment to compensate for changes in cognitive status

using short. simple sentences when communicating with the client

allowing the client to participate in performing ADLS to the best of their ability

discouraging family members from visiting.

giving the client choices with a wide variety of options.

Answer and Explanation

Correct Answer : A,B,C,E

A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.

B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.

C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.

E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.

D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.

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Correct Answer is C

Explanation

C. Range-of-motion (ROM) exercises are essential in preventing contractures. These exercises aim to maintain or improve joint mobility by moving each joint through its full range of movement. They help stretch tight muscles and maintain flexibility, thereby preventing the progression of contractures.

A. While muscle strengthening exercises are beneficial for overall muscle health, in the context of contractures, the primary issue is the shortened and tight muscles. Strengthening exercises alone may not effectively address the contractures and could potentially exacerbate them.

B. Frequent repositioning is crucial to prevent and potentially reverse contractures. By changing the client's position regularly, pressure and stress on specific muscle groups are relieved, which can help prevent further tightening and promote flexibility. This intervention helps maintain joint mobility and prevents contractures from worsening.

D. Weight-bearing activities can be beneficial for joint health and bone density but may not directly address contractures. Contractures involve structural changes in the muscle-tendon unit rather than joint stiffness alone.

A. "What are you using for birth control B. "Are you currently in a relationship?" C. "Is your wife a good cook? D. "What does your husband do?

Correct Answer is B

Explanation

B. This question is also inclusive as it does not assume the client's sexual orientation or relationship status. It allows the client to disclose their current relationship status, whether they are in a relationship with a partner of the same or different gender, or if they are single.

A. This question uses assumes the client's gender and sexual orientation.

C. This question assumes a heterosexual relationship and also implies traditional gender roles. It may not be inclusive as it assumes that the client has a wife and further stereotypes the role of a wife as a cook.

D. This question assumes a heterosexual relationship and may not be inclusive of clients who do not have husbands or who are in same-sex relationships. It also reinforces traditional gender roles by assuming that a husband is the primary breadwinner or has a defined occupation.

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The nurse is providing care for an elderly client who has dementia. Interventions used would include: (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The newly admitted client has contractures of both lower extremities. What nursing intervention should be included in this client's plan of care?

Correct Answer is C

Explanation

Which of these questions, used by the nurse, shows appropriate use of inclusive language?

Correct Answer is B

Explanation

A client is brought into the emergency department for an overdose of morphine. The client has a respiratory rate of 5 to 8 breaths per minute. Which of the following ABG results would the nurse expect to see?

The nurse understands that motivation to learn is strongest when the client:

The nurse's assistant is having difficulty carrying out a delegated task. The first step the nurse should take is to:

It is important for the nurse to ensure that the client's post-operative Jackson-Pratt device is patent because its purpose is to:

The nurse finds a client's pulse to be very weak, but palpable. Documentation should note that this pulse is:

The nurse is completing a cardiac assessment on a client. The pulmonic valve would best be assessed by auscultating at the:

The nurse is providing care for an elderly client who has cognitive changes. The nurse recognizes that which statement regarding dementia and delirium is true?

The inexperienced nurse is reassigned to another unit to care for a critically ill client whose care is beyond her capability. What action should the nurse take first?