A client with coronary artery disease (CAD) is admitted to the medical unit for testing. The client describes having had frequent episodes of angina over the last few days prior to admission. The client is now experiencing shortness of breath, nausea, and chest pressure. After obtaining the client's vital signs, which action should the nurse take next?

Rationale

A. This approach might inadvertently increase feelings of isolation and worsen agitation. Older adults with dementia often benefit from social interaction and engagement. Limiting interaction could lead to increased confusion and behavioral issues.

B. Attempting to correct or argue with the client about their delusions is generally not effective and can escalate agitation. Clients with dementia may not have the cognitive ability to understand or accept reality as others perceive it. Therefore, trying to clarify or correct delusional thoughts is unlikely to be helpful and may increase distress.

C. While maintaining a consistent routine is beneficial for clients with dementia, forcibly awakening the client earlier could disrupt their natural sleep patterns and contribute to increased confusion and agitation. It's important to balance the need for routine with the client's individual sleep and rest patterns.

D. This approach focuses on redirecting the client's attention away from the distressing thoughts and behaviors. Distraction techniques involve engaging the client in activities or topics that they find enjoyable or comforting. Therapeutic communication skills include active listening, empathy, and validating the client's emotions without reinforcing delusions.

Rationale

A. Clenched fists can be a sign of pain in infants. Infants may reflexively clench their fists as a response to discomfort or pain. This behavior is commonly observed during painful procedures or when experiencing pain.

B. While fever can sometimes accompany pain due to inflammation or stress response, it is not typically a reliable indicator of pain in the absence of other signs. Therefore, fever alone is not a specific indicator of pain post-pyloromyotomy.

C. Restlessness or increased agitation can indicate pain in infants. They may squirm, move their arms and legs, or have difficulty settling down. Restlessness is a non-verbal cue that infants use to communicate discomfort or distress.

D. Peripheral pallor could indicate decreased peripheral perfusion, which might occur due to various factors post-operatively, but it is not a direct indicator of pain.

E. Increased respiratory rate can be associated with pain.

F. An increased pulse rate (tachycardia) is a physiological response to pain in infants. Pain activates the sympathetic nervous system, leading to an increased heart rate as the body prepares to respond to stress or discomfort.