Which short-term outcome should the nurse include in the initial treatment plan for a client with dementia?

Expresses no paranoid ideation for at least 1 week.

Performs activities of daily living for 3 sequential days.

Verbalizes no hallucinations and delusions for 48 hours.

Remembers family member's names at their next visit.

Answer and Explanation

The Correct Answer is B

Choice A reason: Reducing paranoid ideation is relevant for psychosis but less common in early dementia, where functional decline is prominent. Supporting ADLs addresses immediate needs and independence, making this less realistic and incorrect for a short-term outcome in a dementia treatment plan.

Choice B reason: Performing activities of daily living (ADLs) for 3 days is a realistic, functional short-term outcome for dementia, promoting independence and quality of life. This aligns with nursing goals for managing cognitive decline, making it the most appropriate initial outcome for the treatment plan.

Choice C reason: Eliminating hallucinations and delusions is more relevant for schizophrenia or advanced dementia with psychosis. Early dementia focuses on functional support like ADLs. This outcome is less achievable short-term, making it incorrect for the initial treatment plan in a dementia client.

Choice D reason: Remembering family names is unrealistic for dementia, where memory loss is progressive. Supporting ADLs is a more achievable short-term goal, enhancing daily functioning. Memory-based outcomes are less feasible, making this incorrect for the initial treatment plan’s short-term focus.

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Correct Answer is A

Explanation

Choice A reason: A mental status examination (MSE) assesses cognition, mood, and thought processes, providing critical data on distractibility and concentration in a short timeframe. This guides the treatment plan for a client with these symptoms, aligning with psychiatric assessment protocols, making it the most important initial assessment.

Choice B reason: Substance use history is relevant but less urgent than an MSE, which directly evaluates current cognitive and emotional state. In 15 minutes, MSE provides immediate data for treatment planning, making substance history secondary and incorrect for the most critical initial assessment.

Choice C reason: Medication compliance informs treatment but does not address the client’s current distractibility and concentration issues as directly as an MSE. The MSE offers real-time insight into symptoms, guiding the plan, making compliance less urgent and incorrect for the primary assessment in this timeframe.

Choice D reason: Motivation for treatment is important but secondary to understanding the client’s current mental state via MSE, which informs immediate interventions for distractibility. Limited time prioritizes objective assessment, making motivation less critical and incorrect for the most important initial treatment planning step.

A. Recommend journaling and time taken in self-reflection. B. Incorporate animated communication techniques. C. Assist the client to identify symptoms of depression. D. Schedule regular periods of time for interaction with client.

Correct Answer is D

Explanation

Choice A reason: Journaling and self-reflection are useful but may overwhelm a depressed client who lacks motivation. Regular nurse-client interaction provides consistent support, fostering trust and engagement, which is more immediate for inpatient care. This intervention is secondary, making it incorrect for demonstrating primary support.

Choice B reason: Animated communication may be inappropriate for depression, where clients often feel withdrawn. Regular interaction with a calm, supportive presence better addresses the client’s need for connection. Animated techniques risk alienating the client, making this incorrect for demonstrating effective support in major depressive disorder.

Choice C reason: Identifying depression symptoms is part of assessment, not ongoing support. Scheduled interactions build therapeutic rapport, directly addressing the client’s emotional needs in depression. Symptom identification is less supportive than consistent presence, making this incorrect for the primary intervention to demonstrate support.

Choice D reason: Scheduling regular interactions demonstrates support by providing consistent, empathetic engagement, countering the isolation of depression. This fosters trust and therapeutic alliance, critical for inpatient psychiatric care, aligning with nursing principles for major depressive disorder management, making it the most effective intervention for support.

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Which short-term outcome should the nurse include in the initial treatment plan for a client with dementia?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the nurse use to demonstrate support of the client?

Correct Answer is D

Explanation

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