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 A

Explanation

Rationale

A. Children with eczema often scratch their itchy skin, which can lead to skin breakdown, bleeding, and secondary infections. Short nails minimize the trauma inflicted on the skin during scratching and help prevent complications.

B. Bathing helps to hydrate the skin and remove allergens, bacteria, and other irritants that can exacerbate eczema. Bathing daily with bath oil helps to moisturize the skin and prevent dryness. Bath oils or emollients should be used instead of harsh soaps, which can strip the skin of natural oils and worsen dryness. However, it's essential to ensure the water is not too hot and to limit bath time to avoid drying out the skin.

C. Moisturizing the skin is a cornerstone of eczema management. Applying a moisturizer, such as baby lotion or emollient cream, helps to hydrate the skin, reduce dryness, and protect the skin barrier. Moisturizers should ideally be applied at least twice daily, especially after bathing or showering when the skin is damp to lock in moisture. Choosing a moisturizer that is fragrance-free and hypoallergenic is beneficial to avoid further irritation.

D. Cotton clothing is recommended for children with eczema because it is breathable and less likely to irritate sensitive skin compared to synthetic fabrics. Cotton allows better air circulation around the skin, which can help prevent overheating and sweating, both of which can exacerbate eczema symptoms. Avoiding wool and synthetic fabrics that can cause friction and irritation is important.

A. The pressure dressing at right femoral area is moist and oozing blood. B. Pulse distal to the femoral artery is weaker on left foot than right foot. C. Right foot is cool to the touch and appears pale and blanched. D. Blood pressure trend is downward and pulse is rapid and irregular.

Correct Answer is C

Explanation

A. While bleeding can occur postoperatively from the catheter insertion site, it is more indicative of venous or capillary bleeding rather than arterial obstruction. Arterial obstruction typically presents with signs related to decreased arterial blood flow rather than external bleeding.

B. This finding suggests a difference in peripheral pulses between the two lower extremities. While it could indicate arterial compromise, the question specifically asks about arterial obstruction at the site of the catheterization (right femoral artery).

C. This finding is concerning for arterial obstruction. Coolness, pallor, and blanching of the right foot indicate decreased arterial blood flow to the extremity. Arterial obstruction can lead to reduced perfusion distal to the occlusion site, resulting in these clinical signs.

D. These vital sign changes could indicate systemic complications, such as shock, rather than isolated arterial obstruction at the femoral artery site. While systemic changes can occur secondary to arterial obstruction, they are not specific indicators of obstruction at the femoral artery.

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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

The nurse is assessing a 4-year-old client with eczema. The child's skin is dry and scaly, and the parent reports that the child frequently scratches the lesions on the skin to the point of causing bleeding. Which guideline is indicated for care of this child?

Correct Answer is A

Explanation

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Correct Answer is C

Explanation

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

While changing a client's postoperative dressing, the nurse observes purulent drainage at the site. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?