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 B
Explanation
Choice A rationale
Roast pork is a protein source and does not contribute to fiber content. However, fresh strawberries are high in fiber and may not be suitable for a low-fiber diet.
Choice B rationale
Roasted turkey is a good source of protein and does not contribute to fiber content. Canned vegetables are typically lower in fiber than their fresh or frozen counterparts because the canning process tends to degrade some of the fiber. Therefore, this food selection indicates that the patient understands the prescribed low-fiber diet.
Choice C rationale
Both baked potatoes with skin and raw carrots are high in fiber. The skin of the potato and raw carrots contain insoluble fiber, which may not be suitable for a patient with ulcerative colitis on a low-fiber diet.
Choice D rationale
Pancakes made from refined flour can be part of a low-fiber diet. However, whole-grain cereals are high in fiber and may not be suitable for a patient with ulcerative colitis on a low-fiber diet.
Correct Answer is []
Explanation
Based on the information provided, the client is most likely experiencinganorexia nervosa.This is suggested by her significant weight loss, bradycardia, hypothermia, lanugo-type hair, and her expressed fear of gaining weight despite being underweight. However, this is a preliminary assessment and a definitive diagnosis should be made by a healthcare professional.
Actions the nurse should take to address this condition include:
- Acknowledge anxious feelings: It’s important to validate the client’s feelings and fears about food and weight gain.This can help build trust and facilitate further discussion about her health.
- Provide emotional support: Emotional support is crucial in managing eating disorders.The nurse can provide reassurance, listen empathetically, and encourage the client to express her feelings.
Parameters the nurse should monitor to assess the client’s progress include:
- Nutritional intake: Monitoring the client’s food and fluid intake can help assess her nutritional status and response to treatment.
- Weight and BMI: Regular monitoring of the client’s weight and BMI can provide objective measures of her nutritional status and response to treatment.
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