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 C

Explanation

Choice A rationale

Auscultating an area six inches below the umbilicus would not provide the most useful data when assessing for possible urinary retention. Auscultation is typically used to assess bowel sounds and not typically used in the assessment of urinary retention.

Choice B rationale

Observing the appearance of the patient’s urine can provide some information about the patient’s hydration status and kidney function, but it would not be the most useful technique for assessing urinary retention.

Choice C rationale

Palpating the area above the pubic symphysis can provide useful data when assessing for possible urinary retention. If the bladder is distended due to urinary retention, it may be palpable in this area.

Choice D rationale

Measuring the girth of the patient’s lower abdomen is not typically used as a method to assess for urinary retention. While an increase in abdominal girth can occur with urinary retention, it is not the most direct or reliable method for assessment.

A. Take prescribed cortisone accurately. B. Use a walker when weakness occurs. C. Increase daily intake of sodium in diet. D. Avoid extreme environmental temperatures.

Correct Answer is A

Explanation

Choice A rationale

Taking prescribed cortisone accurately is crucial for managing multiple sclerosis symptoms. Cortisone is a type of steroid that can reduce inflammation and suppress the immune system, helping to manage MS symptoms.

Choice B rationale

Using a walker when weakness occurs can be beneficial for patients with multiple sclerosis as it can help them maintain mobility and independence. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

Choice C rationale

Increasing daily intake of sodium in the diet is not recommended for patients with multiple sclerosis. High sodium intake can exacerbate symptoms of multiple sclerosis and may increase the risk of relapses.

Choice D rationale

Avoiding extreme environmental temperatures can be beneficial for patients with multiple sclerosis as heat can worsen symptoms. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.

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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

Which assessment technique would provide the most useful data when the nurse is concerned about possible urinary retention?

Correct Answer is C

Explanation

A patient with a history of celiac disease has recently been diagnosed with multiple sclerosis.The nurse is preparing to discharge the patient.What is the most important instruction for the nurse to include in the discharge teaching plan?

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?