An older adult client with dementia is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing.
The client is becoming increasingly agitated and stating the UAP “wants to hurt me and tie me up.”. Which approach should the nurse use with this client?
Clarify reality with the client about delusional thoughts.
Reduce the client’s interaction with others during the day.
Awaken the client earlier for daily morning care.
Use distraction and therapeutic communication skills.
The Correct Answer is D
Choice A rationale
Clarifying reality with the client about delusional thoughts is not the most effective approach when dealing with a client with dementia who is experiencing agitation and delusional thoughts. The cognitive impairment associated with dementia may make it difficult for the client to understand or accept the clarification, which could lead to increased frustration and agitation.
Choice B rationale
Reducing the client’s interaction with others during the day is not the most appropriate approach in this situation. It may lead to increased social isolation and could potentially worsen the client’s agitation and delusions. It does not directly address the client’s emotional distress.
Choice C rationale
Awakening the client earlier for daily morning care may further disrupt the client’s sleep patterns and potentially worsen agitation. It does not address the underlying issue of delusional thoughts and the client’s emotional distress.
Choice D rationale
Using distraction and therapeutic communication skills is the most suitable approach for a client with dementia who is experiencing agitation and delusional thoughts. Distraction techniques can help redirect the client’s focus away from distressing thoughts, and therapeutic communication skills, such as active listening and validation, can help the client feel understood and supported.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B"]
Explanation
Choice A rationale
Fresh or frozen vegetables without sauce are a great choice for someone with hypertension. Vegetables are high in fiber and low in sodium, which can help lower blood pressure. They also contain potassium, which can help balance out the negative effects of sodium.
Choice B rationale
Fruits without sauce are also a good option. Like vegetables, fruits are high in fiber and potassium and low in sodium. They also contain other heart-healthy nutrients like antioxidants.
Choice C rationale
Cottage cheese is typically high in sodium, which can raise blood pressure. Therefore, it’s not the best choice for someone with hypertension.
Choice D rationale
Pickled olives are also high in sodium, making them a poor choice for someone with hypertension.
Choice E rationale
Canned soup is another food that’s typically high in sodium. While low-sodium versions are available, fresh soup made with low-sodium broth and plenty of vegetables would be a healthier choice.
Correct Answer is D
Explanation
The correct answer is Choice D.
Choice D rationale: Keeping the nails trimmed short is crucial for a child with eczema because it minimizes the damage done when the child scratches their skin. Short nails reduce the risk of breaking the skin and causing infections or further irritation, which can exacerbate eczema symptoms. This preventive measure helps maintain the skin's integrity and reduces the risk of secondary infections.
Choice A rationale: Allowing the child to wear only 100% cotton clothing can help reduce skin irritation as cotton is a soft, breathable fabric. However, it is not as directly related to preventing the harm caused by scratching.
Choice B rationale: Applying baby lotion to the skin can help keep the skin moisturized, but it might not be sufficient for eczema management. A more intensive emollient or specific eczema treatment may be needed.
Choice C rationale: Bathing the child daily with bath oil can help moisturize the skin, but over-bathing can sometimes exacerbate eczema. It's important to use gentle, non-irritating bath products and to follow other guidelines, such as trimming nails.
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