As a nurse, you are reviewing the orders and planning initial steps for caring for the same patient.
Which interventions should you perform?

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.

Choice A rationale

While advising family members to monitor for symptoms of illness is important, it’s not the most crucial action for the nurse to take immediately after testing the patient for COVID-194.

Choice B rationale

Implementing droplet precautions, placing the patient in a private room, and keeping the door closed is the most crucial action. This helps prevent the potential spread of COVID-19 to other patients and healthcare workers.

Choice C rationale

Informing the patient to notify others about potential exposure is important, but it’s not the most crucial action immediately after testing.

Choice D rationale

Initiating an IV infusion for the administration of an antiviral drug is not the most crucial action. Antiviral medication is typically administered after a positive test result, not before.