The nursing action most likely to be effective in improving the level of orientation of a client experiencing dementia is:
Assuring the client that the deceased spouse will not be expected home soon.
Telling the client the current day of the month and time in a raised voice.
Turning on a radio station that plays soft rock music.
Encouraging the client to discuss memories of families.
The Correct Answer is B
A. Assuring the client that the deceased spouse will not be expected home soon is not an appropriate intervention for improving orientation. It may further confuse the client or cause distress, as they may not be aware that their spouse has passed away, leading to emotional discomfort rather than improving their orientation.
B. Telling the client the current day of the month and time in a raised voice is an appropriate intervention. People with dementia often struggle with time and place orientation, so providing clear, direct, and simple information (like the day and time) can help them reorient themselves. However, it is essential to communicate in a calm and gentle tone, not necessarily a raised voice, unless the client has hearing issues.
C. Turning on a radio station that plays soft rock music may help with relaxation, but it is unlikely to improve orientation directly. Music may be comforting, but it does not provide concrete information to help the client orient to time, place, or person.
D. Encouraging the client to discuss memories of families may help the client feel emotionally supported, but it does not directly improve their orientation to the present time, which is the primary concern in dementia care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will help you leave this relationship" is not an appropriate response because it assumes the nurse knows what is best for the patient and does not respect her autonomy or immediate choices. The patient has clearly stated she does not want to leave the relationship at this time.
B. "You need to report your husband to the police" is an invasive and potentially coercive statement. While reporting abuse is important, the nurse should provide information and support, not force actions the patient may not be ready to take. Pressuring her could escalate the situation and harm the patient’s trust in healthcare providers.
C. "Let's develop a safety plan for repeated violence" is the most supportive and patient-centered response. It acknowledges the reality of the abuse while offering a non-judgmental, practical approach to help her stay safe. The nurse is giving the patient the option to make informed decisions about her safety, which is empowering.
D. "Here is a list of services that can help you" is helpful, but it lacks the active engagement the patient may need. Developing a personalized safety plan is more immediate and relevant for someone experiencing ongoing abuse.
Correct Answer is D
Explanation
A. Visual hallucinations can occur during alcohol withdrawal, especially in more severe cases such as delirium tremens (DTs). Hallucinations are part of the neuropsychiatric symptoms seen in alcohol withdrawal.
B. Tremors are one of the most common symptoms of alcohol withdrawal. Hand tremors are typically observed and can range from mild to severe.
C. Paroxysmal sweating (or excessive sweating) is also a common symptom of alcohol withdrawal. It occurs due to autonomic instability in the body during withdrawal, and can be quite pronounced.
D. Pupil dilation is not typically a symptom of alcohol withdrawal. In fact, alcohol withdrawal more commonly causes pupil constriction in mild to moderate withdrawal, and pupillary changes are generally less pronounced than other symptoms like tremors, sweating, or anxiety.
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