Which nursing interventions will the nurse include in the plan of care for a confused older adult with dementia to facilitate communication? Select all that apply.

Correct Answer: A

Rationale: The correct answer is A because frequent face-to-face contact helps establish a connection and maintain attention with the confused older adult. This approach allows the nurse to monitor nonverbal cues and adjust communication accordingly. Choices B, C, and D are incorrect. Speaking calmly, simply, and directly (B) is generally helpful but not specific to facilitating communication with a confused older adult with dementia. Using clocks and calendars for orientation (C) may be overwhelming for someone with dementia. Answering questions in detail (D) can lead to confusion and may not be helpful for someone with cognitive impairment.

Correct Answer: A

Rationale: Correct Answer: A (Dimming the lights) Rationale: 1. Dimming the lights helps create a conducive environment for sleep by signaling the body to produce melatonin, a hormone that regulates sleep-wake cycles. 2. Reduced light exposure promotes relaxation and triggers the body's natural sleep mechanisms. 3. Bright lights can interfere with the body's circadian rhythm, making it difficult to fall asleep. Summary of Incorrect Choices: B. Administration of a diuretic is unrelated to promoting sleep and may actually disrupt sleep patterns by causing frequent trips to the bathroom. C. Promoting daytime exercises can be beneficial for overall health but may not directly address disturbed sleep patterns. D. Suggesting a bottle of wine before sleep is not recommended as alcohol can disrupt sleep quality and lead to fragmented sleep patterns.

Correct Answer: A

Rationale: The correct answer is A: An emancipated 16-year-old. Emancipated minors have the legal capacity to provide consent for medical treatments, including participating in clinical trials. They are considered mature and independent enough to make their own healthcare decisions. B: A 4-year-old child lacks the capacity to provide informed consent due to their young age and lack of understanding of the implications of participation in a clinical trial. C: An incompetent adult lacks the mental capacity to make informed decisions, so they cannot give consent for a clinical trial. D: An elder with dementia may lack the capacity to understand the risks and benefits of participating in a clinical trial, therefore cannot provide valid consent.

Correct Answer: B

Rationale: The primary purpose of nursing theories is to provide a framework for nursing practice (Option B). Nursing theories are essential in guiding nurses in their practice by outlining principles, concepts, and values that shape the profession. These theories help nurses understand the rationale behind their actions, make clinical decisions, and provide quality patient care. Option A, which suggests that nursing theories exist to dictate medical interventions, is incorrect. Nursing theories are distinct from medical interventions and focus on nursing-specific concepts such as patient care, holistic health, and human responses to illness. Option C, stating that nursing theories are for establishing healthcare policies, is also incorrect. While nursing theories may influence healthcare policies indirectly by emphasizing the importance of certain approaches to care, their primary goal is to guide nursing practice. Option D, suggesting that nursing theories aim to replace medical guidelines, is incorrect. Nursing theories and medical guidelines serve different purposes, with nursing theories specifically tailored to the unique aspects of nursing practice. In an educational context, understanding the purpose of nursing theories is crucial for nursing students as it forms the foundation of their professional practice. By grasping the role of theories in shaping nursing care, students can better appreciate the significance of evidence-based practice, critical thinking, and effective decision-making in the nursing profession.

Correct Answer: A

Rationale: The correct answer is A) Continue to monitor and record hourly urine output. This is the appropriate action because the urine output is within normal limits for a postoperative male client. It is essential to continue monitoring to ensure there are no sudden changes or trends indicating a potential issue, such as decreased renal function or inadequate fluid intake. Option B) Irrigate the indwelling urinary catheter is incorrect because there is no indication in the scenario that the catheter needs to be irrigated. Doing so without a specific reason can introduce unnecessary risks such as introducing infection. Option C) Increase the I.V. fluid infusion rate is also incorrect as there is no evidence in the scenario to suggest the need for increased fluid intake. Adjusting fluid infusion rates should be based on a comprehensive assessment and not solely on two consecutive hourly urine output measurements. Option D) Notify the physician is unnecessary at this point as the urine output is within normal limits. It is important for nurses to use critical thinking and clinical judgment to determine when physician notification is warranted. In an educational context, this question helps develop the critical thinking skills of nursing students. It emphasizes the importance of monitoring and interpreting patient data accurately before taking action. It also highlights the significance of evidence-based decision-making in nursing practice to provide safe and effective patient care.