A client is diagnosed with Alzheimer's disease. He tells the nurse, "I have a date tonight for Valentine's dance." The most appropriate response is:
"I think you need more medication. I will be right back."
"Your wife passed away last year. Who's your date?"
"Today is (today's date). Tell me about the other dances you've been to."
You're confused. Today is not Valentine's Day."
The Correct Answer is C
A. "I think you need more medication. I will be right back." While medication is an important aspect of managing Alzheimer's disease, this response dismisses the patient's feelings and does not address the emotional content of the statement. The goal is to engage with the patient in a compassionate way, not to assume the medication is the solution.
B. "Your wife passed away last year. Who's your date?" This response may be truthful, but it could be very distressing for the patient. Alzheimer's disease often causes memory loss and confusion, so correcting the patient in this blunt manner may cause unnecessary emotional distress or frustration.
C. "Today is (today's date). Tell me about the other dances you've been to." This is the most appropriate response. It gently redirects the patient to reality by providing the correct date, but it also shows empathy and invites the patient to share pleasant memories. This approach validates the patient's emotions and encourages conversation, which is beneficial for maintaining dignity and engaging the patient in meaningful dialogue.
D. "You're confused. Today is not Valentine's Day." This response may make the patient feel invalidated or upset. Alzheimer's disease often causes confusion and disorientation, so harshly correcting the patient can lead to increased agitation and emotional distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Patient will remain safe in the environment is the priority outcome in both delirium and dementia scenarios. In both conditions, the patient is at an increased risk of harm due to confusion, misinterpretation of reality, and impaired judgment. Ensuring the patient's safety is the first and foremost concern. This could involve managing the patient's environment, preventing falls, using safety measures like bed alarms, and ensuring that wandering is minimized.
B. Patient will acknowledge reality is a desirable goal but not the immediate priority in these cases. In delirium, the patient's altered reality is typically reversible once the underlying cause is addressed. In dementia, reality orientation may be difficult or impossible to fully achieve, so safety is more important.
C. Patient will communicate verbally is important, but in these cases, the patient's safety is more critical. Communication abilities may vary depending on the severity of the delirium or dementia, and focusing on verbal communication may not address the more immediate need for safety.
D. Patient will participate actively in self-care is an important goal for promoting independence, but in the case of delirium and dementia, ensuring the patient's safety must be prioritized first, as these conditions may impair the patient's ability to perform self-care activities safely.
Correct Answer is A
Explanation
A. Physical or chemical means or device that restricts client's freedom to and ability to move about is the most accurate definition of restraint. This includes any method or device used to prevent a patient from moving freely, such as physical devices (like straps or handcuffs) or chemical restraints (medications used to sedate or calm the patient).
B. The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving refers to seclusion, not restraints. Seclusion is a form of isolation, often used when a patient is a danger to themselves or others, but it is distinct from restraints.
C. Pharmacological interventions for management of acute behavioral emergencies refers to the use of medication, but this is not specifically a restraint. Restraints involve preventing movement or controlling behavior through either physical or chemical means, but this definition is more about the use of medication in emergencies rather than restricting movement.
D. Safety measures to prevent a threatened or attempted suicide or some serious bodily injury describes precautionary measures rather than the definition of restraint itself. Restraints are about restricting movement, not necessarily about preventing injury or harm directly.
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