During an indwelling Foley catheterization of a male patient, it is important that the nurse?

Choice A reason: Engaging the client in a walk and family discussion uses therapeutic communication and redirection, common in dementia care. This non-pharmacological approach validates emotions, reduces distress, and promotes calmness by shifting focus to positive memories, aligning with person-centered care principles to address emotional needs first.

Choice B reason: Alprazolam, a benzodiazepine, reduces anxiety but carries risks like sedation and falls in dementia patients. Pharmacological interventions should be secondary to non-pharmacological approaches, as they may exacerbate confusion or dependency. Addressing emotional distress through engagement is preferred before considering medications for anxiety management.

Choice C reason: Olanzapine, an antipsychotic, is used for severe agitation or psychosis in dementia. It poses risks like sedation, extrapyramidal symptoms, and increased mortality in elderly patients. Non-pharmacological interventions, like redirection, are prioritized to manage emotional distress safely, reserving medications for when behavioral approaches fail.

Choice D reason: Isolating the client in their room may increase distress and agitation in dementia patients, as it does not address their emotional needs. Social isolation can worsen confusion and feelings of abandonment. Therapeutic engagement, such as redirection or validation, is more effective in calming the client and fostering trust.

Choice A reason: Leg swelling (edema) is a symptom of heart failure due to fluid retention from poor cardiac output. However, it is less urgent than breathing difficulties, which indicate pulmonary edema, a life-threatening complication. Assessing breathing takes priority, as it directly affects oxygenation, a critical physiological need.

Choice B reason: Difficulty breathing (dyspnea) is a hallmark of heart failure, often due to pulmonary edema from fluid backup in the lungs. This compromises oxygenation, making it a life-threatening symptom requiring immediate assessment. The ABCD-E framework prioritizes breathing, making this the most critical question to evaluate heart failure severity.

Choice C reason: Chest pain may indicate angina or myocardial infarction, which can contribute to heart failure. However, it is less specific to heart failure than dyspnea, which directly signals pulmonary congestion. Breathing difficulties pose a more immediate threat, as they affect oxygenation, a priority in acute heart failure assessment.

Choice D reason: Heart palpitations may occur in heart failure due to arrhythmias but are less specific and urgent than dyspnea. Palpitations may indicate stress or other conditions, but breathing difficulties directly reflect pulmonary edema, a critical complication requiring immediate attention to ensure adequate oxygenation and prevent respiratory failure.