A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?

Calmly ask the client if he would like to listen to some music.

Turn the water on and ask the client to test the temperature.

Firmly tell the client that good hygiene is important.

Obtain assistance to place mitten restraints on the client.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.

Choice B rationale:

Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.

Choice C rationale:

Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.

Choice D rationale:

Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.

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Correct Answer is D

Explanation

Choice A rationale:

A laissez-faire leadership style is characterized by a lack of involvement or control, and it is not typically associated with perpetrators of child abuse.

Choice B rationale:

Self-blame for financial problems may lead to stress but is not a characteristic finding of perpetrators of child abuse.

Choice C rationale:

High self-esteem is not typically associated with perpetrators of child abuse. In fact, abusers often have low self-esteem and exert power and control over others to compensate for it.

Choice D rationale:

Perpetrators of child abuse often have rigid expectations of behavior from their children and may employ authoritarian parenting styles. This characteristic can contribute to abusive behaviors.

A. "Avoid breastfeeding for 3 days after receiving the vaccine.” B. "Avoid pregnancy for at least 28 days after receiving the vaccine.” C. "If you are allergic to gluten you should not receive this vaccine.” D. "Your partner should also receive the MMR vaccine.”

Correct Answer is B

Explanation

Choice A rationale:

The nurse should not include the instruction to "Avoid breastfeeding for 3 days after receiving the vaccine." This is not a necessary precaution for the MMR vaccine. Breastfeeding can continue after the MMR vaccination without any adverse effects on the infant.

Choice B rationale:

The correct instruction is to "Avoid pregnancy for at least 28 days after receiving the vaccine." This is because the MMR vaccine is a live attenuated vaccine, and there is a theoretical risk of transmitting the virus to a developing fetus. Waiting for 28 days after vaccination allows the woman's immune system to respond to the vaccine and reduce any potential risk to the fetus. This is especially important during the postpartum period when a woman may be at risk of becoming pregnant again.

Choice C rationale:

The statement "If you are allergic to gluten, you should not receive this vaccine" is not accurate. The MMR vaccine does not contain gluten as an ingredient. Allergic reactions to the MMR vaccine are generally related to components of the vaccine itself, not gluten.

Choice D rationale:

The instruction to "Your partner should also receive the MMR vaccine" is not a standard recommendation for postpartum women. While it is essential for individuals to be up-to-date on their vaccinations, the focus in this scenario should be on the postpartum woman receiving the MMR vaccine to protect herself and any future pregnancies.

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A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.The client becomes agitated and combative when the nurse approaches him.Which of the following actions should the nurse plan to take?

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A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?