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","B","E"]

Explanation

Choice A reason: Selegiline, an MAOI, can cause hypertensive crisis, especially with dietary tyramine or drug interactions. Withholding the next dose prevents further escalation of the client’s severe hypertension (200/110 mm Hg), aligning with pharmacology protocols for MAOI-related crises, making this a critical nursing action.

Choice B reason: Monitoring blood pressure and pulse every 15 minutes tracks the client’s hypertensive crisis, ensuring timely detection of changes in this life-threatening condition. Frequent vital signs are essential for managing MAOI-induced hypertension, aligning with critical care standards, making this an appropriate action.

Choice C reason: Measuring hourly urinary output is relevant for fluid status but not urgent in a hypertensive crisis. Blood pressure monitoring and provider notification address the immediate danger of selegiline’s effects, making urinary output less critical and incorrect for this acute scenario’s priority actions.

Choice D reason: Discontinuing the IV infusion is unnecessary, as lactated Ringer’s with KCl is not causing the hypertension. Selegiline’s MAOI effects are the likely culprit. Stopping the IV risks fluid imbalance without addressing the crisis, making this incorrect for managing the client’s condition.

Choice E reason: Notifying the healthcare provider is essential, as the client’s severe headache and hypertension (200/110 mm Hg) suggest an MAOI-related crisis requiring urgent medical intervention. This ensures rapid management, aligning with patient safety protocols, making it a critical action for the nurse to take.

A. "Do you often feel sad?" B. "Have you experienced recent stresses?" C. "What foods do you like to eat?" D. "Have you experienced sleep changes?"

Correct Answer is A

Explanation

Choice A reason: Asking “Do you often feel sad?” directly assesses the core symptom of depression, low mood, critical for diagnosis. The client’s reported fatigue and poor sleep suggest depression, and confirming sadness strengthens the assessment, aligning with psychiatric diagnostic criteria, making this the most important question.

Choice B reason: Recent stresses may contribute to depression but are less specific than sadness, the hallmark symptom. Asking about mood directly confirms depression, while stress is a secondary factor. This question is less critical, making it incorrect for the primary depression assessment in this client.

Choice C reason: Food preferences are irrelevant to depression assessment, as they do not address mood, sleep, or concentration issues. Asking about sadness targets the core depressive symptom, making this incorrect, as dietary habits do not provide diagnostic clarity for the client’s reported symptoms.

Choice D reason: Sleep changes are already reported (4-5 hours), so asking about them is redundant. Confirming sadness directly assesses the primary depressive symptom, strengthening the diagnosis. This question is less essential, making it incorrect compared to probing the client’s emotional state for depression.

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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","B","E"]

Explanation

A client at the mental health center reports difficulty concentrating at work, feeling very tired during the day, and sleeping 4 to 5 hours at night. To further assess for depression, which question is most important for the nurse to ask?

Correct Answer is A

Explanation

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