An older adult client with dementia is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing.
The client is becoming increasingly agitated and stating the UAP “wants to hurt me and tie me up.”. Which approach should the nurse use with this client?
Clarify reality with the client about delusional thoughts.
Reduce the client’s interaction with others during the day.
Awaken the client earlier for daily morning care.
Use distraction and therapeutic communication skills.
The Correct Answer is D
Choice A rationale
Clarifying reality with the client about delusional thoughts is not the most effective approach when dealing with a client with dementia who is experiencing agitation and delusional thoughts. The cognitive impairment associated with dementia may make it difficult for the client to understand or accept the clarification, which could lead to increased frustration and agitation.
Choice B rationale
Reducing the client’s interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and could potentially worsen the client’s agitation and delusions. It does not directly address the client’s emotional distress.
Choice C rationale
Awakening the client earlier for daily morning care may further disrupt the client’s sleep patterns and potentially worsen agitation. It does not address the underlying issue of delusional thoughts and the client’s emotional distress.
Choice D rationale
Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client’s focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Setting up supplemental oxygen delivery is not the immediate action the nurse should take. The patient’s FiO2 is currently at 35%, which is within the normal range.
Choice B rationale
Increasing the fraction of inspired oxygen is not necessary at this time. The patient’s current FiO2 is within the normal range.
Choice C rationale
The nurse should gather supplies for extubation. As the patient is due to start ventilator weaning, preparing for extubation is the next logical step. This involves having all necessary equipment and personnel ready for the procedure.
Choice D rationale
Placing a nasogastric tube is not the immediate action the nurse should take. While a nasogastric tube can be used to provide nutrition and medication, it is not directly related to the process of ventilator weaning.
Correct Answer is {"dropdown-group-1":"C"}
Explanation
Based on the client’s history and physical, the nurse notes that this postpartum client is most at risk for developingC. Postpartum hemorrhage.
The client’s laboratory results show a decrease in red blood cells (RBC), hematocrit, and hemoglobin levels, which are all signs of blood loss. Additionally, the nurse’s notes mention moderate lochia rubra with small clots, which could be a sign of postpartum hemorrhage. The firm fundus at the umbilicus is a good sign, but the blood loss output and decreased blood values indicate that the client is at risk for postpartum hemorrhage.
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