A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

Complete the bath even if the client is in distress.

Allow the client to select the temperature of the bath water.

Give detailed instructions for the client to follow.

Use distractions when bathing the client.

Answer and Explanation

The Correct Answer is D

A. Complete the bath even if the client is in distress. – Forcing the bath can increase agitation and damage trust. If the client becomes distressed, pause, reassure, and try again later.

B. Allow the client to select the temperature of the bath water. – Clients with dementia may have impaired sensory perception, increasing the risk of burns or discomfort. The nurse should check the water temperature to ensure safety.

C. Give detailed instructions for the client to follow. – Clients with dementia may struggle to process multiple steps, leading to frustration. Instead, use simple, one-step instructions and gentle guidance.

D. Use distractions when bathing the client. Clients with dementia may experience anxiety, agitation, or distress during bathing. Using distractions, such as playing soothing music, talking about familiar topics, or providing a comforting touch, can help make the experience less stressful and more cooperative.

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Correct Answer is A

Explanation

The development of erythema (redness) along the path of the vein indicates phlebitis at the IV site. Phlebitis refers to inﬂammation of the vein, often caused by irritation or infection. When phlebitis occurs, the vein becomes inﬂamed and can appear red, warm, and tender to touch. Erythema is a characteristic sign of phlebitis and suggests that the client's IV site has become irritated or infected.

Let's now discuss why the other

Options are not the correct answers:

Coolness of the client's left forearm: Coolness of the forearm is not typically associated with phlebitis. Instead, it may suggest compromised blood ﬂow to the area, such as arterial insufficiency, rather than inﬂammation of the vein.
Pallor of the client's left forearm: Pallor, or paleness, of the forearm is not a typical finding in phlebitis. It usually indicates reduced blood ﬂow or decreased oxygenation to the area, which can be caused by factors other than inﬂammation of the vein.
Pitting edema at the insertion site: Pitting edema refers to the indentation that remains when pressure is applied to an area of swelling and then release. While edema can occur at the insertion site of an IV, it is not a specific indicator of phlebitis. Edema can result from multiple causes, such as ﬂuid overload or localized inﬂammation, and its presence does not necessarily confirm the presence of phlebitis.

In summary, the presence of erythema along the path of the vein is the finding that indicates the development of phlebitis at the IV site. This redness suggests inﬂammation of the vein, which can be caused by various factors including irritation or infection. The other

Options, such as coolness of the forearm, pallor of the forearm, or pitting edema at the insertion site, are not specific indicators of phlebitis and may be associated with diﬀerent underlying conditions or factors.

A. Increased skin elasticity B. Reduced sweat production C. Increased production of oils D. Thickened outer layer of skin

Correct Answer is B

Explanation

The correct answer is that the nurse should expect to find reduced sweat production when performing a skin assessment on an older adult client. As we age, our skin gradually loses its ability to produce sweat and oil, which can result in dry skin¹.

Options a, c and d are not expected findings when performing a skin assessment on an older adult client. Increased skin elasticity, increased production of oils and thickened outer layer of skin are not typical age- related changes.

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A nurse is preparing to bathe a client who has dementia. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who is receiving continuous IV ﬂuid therapy via a peripheral vein in the left forearm. Which of the following findings indicates that the client has developed phlebitis at the IV site?

Correct Answer is A

Explanation

A nurse is performing a skin assessment on an older adult client. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

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