An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Reduce the client's interaction with others during the day.

Clarify reality with the client about delusional thoughts.

Awaken the client earlier for daily morning care.

Use distraction and therapeutic communication skills.

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is ["1.3"]

Explanation

Convert pounds to kilograms.

1 pound = 0.453592 kilograms
132 pounds * 0.453592 kg/pound = 59.87 kilograms

Step 2: Calculate the total dose in micrograms.

44 micrograms/kilogram * 59.87 kilograms = 2635.08 micrograms

Step 3: Convert micrograms to milligrams.

1 milligram = 1000 micrograms
2635.08 micrograms / 1000 micrograms/milligram = 2.63508 milligrams

Step 4: Calculate the volume to be administered.

Concentration of lorazepam = 2 milligrams/milliliter
Volume = Dose / Concentration
Volume = 2.63508 milligrams / 2 milligrams/milliliter = 1.31754 milliliters

Therefore, the nurse should administer approximately 1.3milliliters of the lorazepam solution.

A. Fluid resuscitation due to capillary leaking. B. Replacement of insensible water loss. C. Extension of plasma until blood is available. D. Restoration of electrolyte balance.

Correct Answer is A

Explanation

Rationale

A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.

B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.

C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.

D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.

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An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["1.3"]

Explanation

Correct Answer is A

Explanation

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