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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Choice A rationale

Evaluating the integrity of the IV insertion site is important, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.

Choice B rationale

Encouraging the patient to take deep breaths can help with overall comfort and oxygenation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.

Choice C rationale

Assessing distal lower extremity capillary refill can provide information about the patient’s overall circulation, but it does not directly address the patient’s complaint of pain at the right groin insertion site following a cardiac catheterization.

Choice D rationale

Inspecting the femoral site for hematoma formation is the most appropriate action in response to the patient’s complaint of pain at the right groin insertion site after a cardiac catheterization. Hematoma formation is a potential complication of this procedure and can lead to further complications if not addressed promptly. Ulcerative colitisUlcerative colitis Explore

A. Asthma related to environmental factors B. COPD related to smoking C. Pneumonia related to bacterial infection D. Tuberculosis related to Mycobacterium tuberculosis

Correct Answer is A

Explanation

Choice A rationale

The patient’s history of asthma, previous hospitalizations for asthma-related symptoms, and the current presentation of difficulty breathing and wheezing suggest that she is likely experiencing an asthma exacerbation related to environmental factors. Asthma is a chronic condition that can cause symptoms such as wheezing, shortness of breath, and chest tightness, which the patient is currently experiencing. Environmental factors such as allergens, air pollution, and changes in weather can trigger asthma symptoms.

Choice B rationale

While smoking is a major risk factor for COPD, the patient denies smoking. Additionally, COPD is more common in older adults, and the patient is only 22 years old. Therefore, it is less likely that her symptoms are due to COPD.

Choice C rationale

Pneumonia is typically associated with additional symptoms such as fever, cough with phlegm, and chest pain. The patient’s symptoms do not align with a typical presentation of pneumonia.

Choice D rationale

Tuberculosis is a bacterial infection that typically presents with a chronic cough, weight loss, and night sweats. The patient’s symptoms do not align with a typical presentation of tuberculosis.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

Correct Answer is A

Explanation

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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?