Examkin

Question

Difficulty: MediumBasic Care and Comfort

An older adult client with a history of moderate dementia is admitted to the medical-surgical unit with dehydration and generalized weakness. The healthcare provider prescribes oral rehydration and the insertion of a peripheral intravenous (IV) catheter for fluid replacement. Which nursing intervention is most appropriate to include in the client's plan of care?

  1. A
    Instruct the unlicensed assistive personnel to perform an initial swallowing evaluation before offering oral fluids.
  2. B
    Document the client's decreased thirst mechanism as an expected consequence of aging that requires no specific action.
  3. Offer the client small, frequent sips of preferred beverages using a high-contrast, brightly colored cup.Answer
  4. D
    Apply soft wrist restraints to ensure the client does not dislodge the newly inserted peripheral IV catheter.

Answer

The most appropriate intervention is to offer the client small, frequent sips of preferred beverages using a high-contrast, brightly colored cup.
Offering small, frequent sips in a brightly colored cup is the most appropriate basic care intervention. Clients with dementia often experience visual processing deficits and can become overwhelmed by large volumes of fluid or food at one time. A high-contrast cup improves visibility, and frequent, manageable prompting encourages adequate intake without causing distress.

Step-by-Step Solution

1
Analyze the client's clinical presentation and specific needs.
The client is an older adult with moderate dementia, dehydration, and generalized weakness.
Understanding the client's baseline cognitive and physical status is essential for planning safe, individualized care.
2
Evaluate the proposed interventions against safety and delegation standards.
Delegating an assessment to a UAP, ignoring pathological dehydration, and using restraints without alternatives are identified as unsafe or inappropriate practices.
Nursing actions must adhere to legal guidelines, scope of practice, and evidence-based standards.
3
Select the intervention that promotes basic care and comfort while accommodating cognitive deficits.
Offering small, frequent sips in a high-contrast cup is selected as the correct action.
This approach actively treats the dehydration while adapting to the visual and cognitive needs typical of a client with dementia.

Key Concept

Promoting Nutrition and Hydration in Clients with Cognitive Impairment
Rate this question

Topics

Basic Care and Comfort

More questions from this topic