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
Production of extra platelets is not the primary pathophysiological process in Disseminated Intravascular Coagulation (DIC). While the body may try to produce more platelets in response to the widespread clotting, this is not the cause of the coagulation problem.
Choice B rationale
Depletion of clotting factors is a key feature of DIC. In the initial phase of DIC, there is an overactive clotting process leading to the formation of small blood clots throughout the body’s blood vessels. This overactive clotting uses up platelets and clotting factors, leading to a state where the body is unable to control bleeding, which is the second phase of DIC34.
Choice C rationale
Inhibition of red blood cell production is not a primary feature of DIC. While DIC can lead to anemia due to blood loss from excessive bleeding, it does not directly inhibit the production of red blood cells.
Choice D rationale
Activation of complement pathways is part of the body’s immune response and is not the primary cause of the coagulation problem in DIC34.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Choice A rationale
Decreased range of motion is generally associated with a rotator cuff injury. This is because the rotator cuff is a group of muscles and tendons that surround the shoulder joint, keeping the head of the upper arm bone firmly within the shallow socket of the shoulder. When these muscles or tendons are injured, it can limit the shoulder’s range of motion.
Choice B rationale
Pain with movement can be a symptom of both a rotator cuff injury and a humeral fracture. Both conditions involve structures that are integral to the movement of the arm, and damage to these structures can cause pain when they are moved or put under strain.
Choice C rationale
Reduced strength in the left upper extremity is more commonly associated with a rotator cuff injury. The rotator cuff is responsible for the stability of the shoulder joint and enables the arm to lift and rotate. An injury to the rotator cuff can therefore lead to a reduction in the strength of the arm.
Choice D rationale
Reduced pulse distal to the injury is more commonly associated with a humeral fracture. This is because a fracture to the humerus could potentially damage the blood vessels running along the bone, leading to a reduced pulse further down the arm.
Choice E rationale
Coolness of the skin is more commonly associated with a humeral fracture. This could be due to damage to the blood vessels, leading to reduced blood flow and therefore a lower skin temperature.
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