A nurse is assisting in the care of a client. Nurses' Notes

2000:

The client presents to the emergency department and states, "I have been assaulted." The client was immediately placed in a treatment

room. 2015:

"The client states they were out with friends this evening and had "a little too much to drink." The client states that they fell asleep at their friend's house and when they woke up all of their clothes were off and their genitals were sore. The client states, "I think someone had sex with me, but I don't remember anything." The client reports a history of depression. The client is a full-time college student who lives with roommates. The client admits to drinking socially but denies illicit drug use and tobacco use.

Which of the following interventions should the nurse plan to implement? Select all that apply.

By acknowledging and validating the client's feelings of fear and concern, the nurse establishes a supportive and empathetic approach. This response helps build trust and rapport with the client, creating an environment where open communication is encouraged. Engaging in further discussion allows the client to express their thoughts and beliefs, which can aid in understanding their perspective and providing appropriate care.

Option A is not the best response as it directly denies the client's belief, which can further escalate their paranoia and potentially damage the therapeutic relationship.

Option B is also not the best response as it challenges the client's belief without providing validation or understanding. It may make the client defensive and reluctant to share their thoughts further.

Option D is not the best response as it focuses on questioning the client's belief without providing support or empathy. It does not address the underlying fear and may not help the client feel heard or understood.

Correct answers: A, C, D

A. Provide a stimulating environment for the client. A structured and stimulating environment can help maintain cognitive function and reduce restlessness or agitation. Activities such as music therapy, puzzles, or light exercise can be beneficial.

C. Limit the number of choices for the client. Too many choices can be overwhelming for a client with Alzheimer's disease, leading to frustration and anxiety. Providing limited and simple choices helps them feel more in control without confusion.

D. Use written signs to assist the client with locating the bathroom. Clients with Alzheimer's may have difficulty recognizing familiar places. Labeling key areas, such as the bathroom or bedroom, with clear written signs or pictures can help them navigate their environment independently.

Incorrect:

B. Use confrontation to manage the client's behavior. Confrontation can lead to increased agitation, anxiety, or aggression in clients with Alzheimer's. Instead, caregivers should use redirection, reassurance, and validation therapy to manage behaviors.