The nurse is performing a history and physical assessment for a client in the clinic with moderate dementia. The client becomes agitated when asked questions and inquires why so many questions are being asked. What are the best actions for the nurse to take to obtain the necessary data? Select all that apply.
Persistently ask the same question until answered.
Give the client ample time to answer the questions asked.
Ask simple questions instead of compound questions.
Provide simple explanations to the client as often as required.
Take frequent breaks during the interview process.
Correct Answer : B,C,D,E
Choice A reason: Persistently asking the same question can increase agitation in clients with dementia.
Choice B reason: Allowing ample time for responses can reduce pressure and agitation in clients with dementia.
Choice C reason: Simple questions are easier for clients with dementia to understand and respond to.
Choice D reason: Providing simple explanations can help clients with dementia understand the purpose of the questions.
Choice E reason: Taking frequent breaks can help prevent fatigue and agitation during the assessment process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: This statement reflects a partial understanding of the control issues associated with anorexia but does not indicate a full understanding of the disorder's complexity or the family's role in recovery.
Choice B reason: This statement suggests a lack of understanding of anorexia nervosa, as it is not a phase but a serious mental health condition that requires professional treatment.
Choice C reason: While issues with sexual identity can be stressful, they are not typically the cause of anorexia nervosa, which is characterized by an intense fear of gaining weight and a distorted body image.
Choice D reason: Recognizing a codependent relationship and the enabling of unhealthy behaviors shows an understanding of the dynamics that can contribute to the maintenance of an eating disorder like anorexia nervosa.
Correct Answer is A
Explanation
Choice A reason: Projection involves attributing one's own unacceptable feelings or thoughts to others, which may be the case when the student blames the teacher for their own failure.
Choice B reason: Displacement involves shifting negative feelings to a less threatening object or person, which is not clearly indicated in this scenario.
Choice C reason: Rationalization involves justifying behaviors or feelings with logical reasons, often avoiding the true reasons, which does not seem to apply here.
Choice D reason: Denial involves refusing to accept reality or facts, which is not the defense mechanism being demonstrated by the student's behavior of blaming the teacher.
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