A nurse is preparing to irrigate an adult client's ear due to cerumen accumulation. Which of the following actions should the nurse take?

Rationale:

A. Reinforce orientation to time, place, and person: Regularly providing cues about the current time, location, and people helps reduce confusion and anxiety in clients with dementia. Orientation reinforcement supports cognitive functioning and promotes a sense of safety.

B. Refute the client’s delusions using logic: Arguing or attempting to correct delusions can increase agitation and distress. Therapeutic communication focuses on validation and redirection rather than confrontation, making this approach inappropriate for dementia care.

C. Establish eye contact when communicating with the client: Maintaining eye contact helps ensure the client’s attention and conveys engagement and respect. It enhances understanding and supports effective communication, especially when verbal comprehension may be impaired.

D. Give the client one simple direction at a time: Breaking tasks into single, clear instructions reduces cognitive overload and frustration. This approach increases the likelihood that the client can follow directions and participate successfully in activities of daily living.

E. Allow the client to choose among a variety of activities each day: While offering choices promotes autonomy, offering a large variety can be overwhelming for a client with dementia, leading to confusion, anxiety, and decision paralysis. The nurse should offer limited choices

Rationale:

A. Place the client in supine position: The supine position is not ideal for paracentesis. The procedure is typically performed with the client sitting upright on the edge of the bed or in a high Fowler’s position, allowing fluid to collect in the lower abdomen and reducing the risk of organ puncture.

B. Ensure the client has a full bladder: A full bladder increases the risk of bladder puncture during paracentesis. Clients are usually asked to void before the procedure to minimize this risk and promote safety.

C. Obtain a creatinine level: While kidney function may be relevant to overall health, measuring creatinine is not required specifically for paracentesis. The procedure focuses on removing ascitic fluid and assessing for infection or other complications, not directly on renal function.

D. Weigh the client: Weighing the client before the procedure establishes a baseline to evaluate the amount of fluid removed and monitor changes in fluid status. Pre- and post-procedure weights help assess effectiveness and detect complications such as hypotension or fluid shifts.