An elderly client with dementia and paranoia is refusing restorative nursing care. What initial approach should the nurse take?

Prepare a complex care plan without involving the client.

Restrict movement until the client complies.

Offer reassurance and explain the purpose of the care plan.

Dismiss the client's refusal and proceed with care.

Answer and Explanation

The Correct Answer is C

A. Prepare a complex care plan without involving the client disregards the client’s autonomy and can increase anxiety or resistance. Even with cognitive impairment, involving the client in care decisions helps promote trust and cooperation.

B. Restrict movement until the client complies is coercive and can cause distress, escalate agitation, and violate ethical principles of autonomy and dignity. Physical restrictions should be a last resort and only used for safety.

C. Offer reassurance and explain the purpose of the care plan is the appropriate initial approach. Clients with dementia and paranoia may refuse care due to fear or misunderstanding. Providing calm, clear explanations, using simple language, and offering reassurance helps reduce anxiety, gain cooperation, and preserve dignity. Engaging the client respectfully promotes trust and increases the likelihood of successful restorative care.

D. Dismiss the client's refusal and proceed with care violates the client’s autonomy, may escalate paranoia or agitation, and can damage the nurse-client relationship. Forced care should be avoided unless there is an immediate threat to safety.

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Correct Answer is B

Explanation

A. An interprofessional team consists of members from different health care professions working collaboratively, such as nurses, physicians, social workers, pharmacists, and therapists. Since the team described includes only LPNs and RNs (both nurses), it does not meet the definition of interprofessional.

B. An intraprofessional team consists of members within the same profession working together. LPNs and RNs are both members of the nursing profession, although they have different scopes of practice and levels of education. Therefore, a team made up of LPNs and RNs is considered an intraprofessional team.

C. A professional organization is an association that supports members of a specific profession through advocacy, education, and standards of practice. It does not directly describe a team providing bedside client care.

D. Shared governance is a leadership and decision-making model in which staff nurses participate in organizational policy development and practice decisions. It refers to management structure rather than a specific care team composition.

A. Nonmaleficence B. Beneficence C. Justice D. Autonomy

Correct Answer is A

Explanation

A. Nonmaleficence means “do no harm.” By arranging for an aid to sit with the client overnight instead of using physical restraints, the nurse is preventing potential harm that restraints could cause, such as injury, psychological trauma, or loss of dignity. This action exemplifies the ethical obligation to minimize harm while providing care.

B. Beneficence refers to taking actions that actively promote the well-being of the client, such as providing comfort, treatment, or health promotion. While the nurse’s action may also benefit the client, the primary ethical focus here is preventing harm, which aligns more directly with nonmaleficence.

C. Justice involves fairness in the distribution of healthcare resources and treatment. This principle is not the primary consideration in deciding to avoid restraints in this scenario.

D. Autonomy is the client’s right to make decisions about their own care. While respecting autonomy is important, the decision to prevent harm by providing an aid is ethically centered on protecting the client rather than directly honoring choice.

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An elderly client with dementia and paranoia is refusing restorative nursing care. What initial approach should the nurse take?

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