A nurse is preparing to provide morning hygiene care for a client who has Alzheimer's disease.
The client becomes agitated and combative when the nurse approaches him.
Which of the following actions should the nurse plan to take?
Calmly ask the client if he would like to listen to some music.
Turn the water on and ask the client to test the temperature.
Firmly tell the client that good hygiene is important.
Obtain assistance to place mitten restraints on the client.
The Correct Answer is A
Choice A rationale:
It is essential for the nurse to employ non-pharmacological interventions to manage behavioral issues in clients with Alzheimer's disease. Offering to play music is a suitable approach to distract and soothe the agitated client. Music can have a calming effect and may help reduce anxiety and agitation in clients with dementia. It is a safe and non-invasive intervention that respects the client's autonomy and preferences.
Choice B rationale:
Turning the water on and asking the client to test the temperature (choice B) may not be an appropriate initial response. This action may increase the client's agitation as it involves immediate physical contact and may not address the underlying issue of the client's distress.
Choice C rationale:
Firmly telling the client that good hygiene is important (choice C) is not a recommended approach. Using a firm tone or being authoritative can escalate the client's agitation and may not effectively address the behavioral issue. It's important to use a calm and respectful approach when caring for clients with Alzheimer's disease.
Choice D rationale:
Obtaining assistance to place mitten restraints on the client (choice D) should not be the first choice. Restraints should only be used as a last resort when other methods have failed, and they should be used in accordance with institutional policies and guidelines. Restraints can have adverse physical and psychological effects and should be avoided whenever possible.
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Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Massaging the affected extremity is contraindicated in a client with deep-vein thrombosis (DVT) Massaging the area can dislodge the blood clot, leading to embolism and potentially life-threatening complications.
Choice B rationale:
Administering aspirin for pain is not the appropriate action for a client with deep-vein thrombosis. Aspirin is not the primary treatment for DVT, and it does not address the underlying cause or prevent further clot formation.
Choice C rationale:
Initiating bed rest is the correct action for a client with deep-vein thrombosis. Bed rest helps to reduce the risk of clot dislodgement and embolism. The client should avoid unnecessary movement and keep the affected leg elevated to promote blood flow and prevent complications.
Choice D rationale:
Applying an ice pack to the affected extremity is not the recommended intervention for a client with deep-vein thrombosis. Cold application can cause vasoconstriction, potentially worsening the condition by reducing blood flow to the already affected area.
Correct Answer is C
Explanation
Choice A rationale:
An entry on a nursing blog, while potentially informative, does not provide the same level of evidence-based information as a peer-reviewed journal article. Blog posts may not undergo rigorous peer review and may lack the scientific rigor and credibility associated with peer-reviewed research. Therefore, choice A is not the best source for evidence-based information.
Choice B rationale:
Information from a wound care product vendor may be biased and influenced by commercial interests. Vendors often aim to promote their products, and the information they provide may not be impartial or based on rigorous scientific research. Therefore, choice B is not the best source for evidence-based information.
Choice C rationale:
A peer-reviewed journal article is considered one of the most reliable sources of evidence-based information in healthcare. Such articles undergo a thorough review process by experts in the field to ensure the accuracy, quality, and validity of the research findings. Peer-reviewed articles provide credible and up-to-date information based on scientific research and are widely recognized as a gold standard in evidence-based practice. Therefore, choice C is the correct answer as it offers the best evidence-based information.
Choice D rationale:
First-hand experience with wound care products, while valuable, may not necessarily provide the most comprehensive or up-to-date information. Personal experiences can vary, and healthcare practices evolve over time based on research and new evidence. Therefore, choice D is not the best source for evidence-based information.
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