A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

Remotivation

Orientation to reality

Guided imagery

Validation

Answer and Explanation

The Correct Answer is D

Validation. Validation is a therapeutic technique that involves acknowledging and accepting the feelings and emotions of the person with dementia, even if they are not based on reality. Validation helps to reduce agitation and anxiety and promotes dignity and respect.

The other choices are not correct for the following reasons:

Remotivation is a technique that aims to stimulate the person's interest in the present and future, by providing factual information and encouraging participation in activities. Remotivation may not be appropriate for someone who is agitated and living in the past.

Orientation to reality is a technique that involves correcting the person's misperceptions and confusions, by providing factual information about time, place, and identity. Orientation to reality may increase agitation and frustration and may damage the person's self-esteem.

Guided imagery is a technique that involves using mental images to promote relaxation and well-being. Guided imagery may not be effective for someone who has difficulty with attention, concentration and memory.

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Correct Answer is B

Explanation

Increasing feelings of anger are a common symptom of PTSD after a sexual assault, as survivors may feel violated, powerless, or betrayed by the perpetrator or others. Anger can also be a way of coping with fear, anxiety, or guilt that may arise from the trauma.

Choice A is not correct because the increasing sense of attachment to others is not a typical response to sexual assault. Survivors may experience difficulties in trusting or relating to others, especially those who remind them of the assault or who do not support them.

Choice C is not correct because the constant need to talk about the event is not a characteristic of PTSD. Survivors may avoid thinking or talking about the trauma, as it can trigger distressing emotions or memories. Some survivors may choose to share their experiences with others, but this does not indicate PTSD.

Choice D is not correct because sleeping 12 hr or more each day is not an expected finding of PTSD after a sexual assault. Survivors may have trouble falling or staying asleep, or experience nightmares or flashbacks that disrupt their sleep quality. Sleeping too much can also be a sign of depression, which can co-occur with PTSD.

A. Place the client in a private room. B. Determine the client's level of disorientation. C. Pad the side rails of the bed with towels. D. Accompany the client when ambulating.

Correct Answer is D

Explanation

Accompany the client when ambulating. The nurse’s priority when caring for a client with alcohol use disorder and who is experiencing withdrawal symptoms is to prevent harm to the client. Physiologic manifestations of alcohol withdrawal syndrome include seizures, delirium tremens (DTs), and hallucinations. Therefore, ensuring the client’s safety is of the utmost importance. Accompanying the client when ambulating is the priority intervention as alcohol withdrawal may lead to ataxia, weakness, and dizziness which may lead to falls.

Choice A, placing the client in a private room, does not address the client’s physical needs.

Choice B, determining the client's level of disorientation, is something necessary to assess but not the priority.

Choice C, padding the side rails of the bed with towels, is not the priority intervention, and contributes little to the prevention of falls.

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A nurse is caring for an older adult client who has dementia and is agitated. The client says, "I have to go home and see my mother." The nurse replies, "You miss your mother." Which of the following therapeutic techniques is the nurse using?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has posttraumatic stress disorder (PTSD) following a sexual assault. Which of the following is an expected finding?

Correct Answer is B

Explanation

A nurse in an addiction rehabilitation center is contributing to the plan of care for a newly admitted client who has an alcohol use disorder. Which of the following interventions is the nurse's priority?

Correct Answer is D

Explanation

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