An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Reduce the client's interaction with others during the day.

Clarify reality with the client about delusional thoughts.

Awaken the client earlier for daily morning care.

Use distraction and therapeutic communication skills.

Answer and Explanation

The Correct Answer is D

Rationale

A. This approach might inadvertently increase feelings of isolation and worsen agitation. Older adults with dementia often benefit from social interaction and engagement. Limiting interaction could lead to increased confusion and behavioral issues.

B. Attempting to correct or argue with the client about their delusions is generally not effective and can escalate agitation. Clients with dementia may not have the cognitive ability to understand or accept reality as others perceive it. Therefore, trying to clarify or correct delusional thoughts is unlikely to be helpful and may increase distress.

C. While maintaining a consistent routine is beneficial for clients with dementia, forcibly awakening the client earlier could disrupt their natural sleep patterns and contribute to increased confusion and agitation. It's important to balance the need for routine with the client's individual sleep and rest patterns.

D. This approach focuses on redirecting the client's attention away from the distressing thoughts and behaviors. Distraction techniques involve engaging the client in activities or topics that they find enjoyable or comforting. Therapeutic communication skills include active listening, empathy, and validating the client's emotions without reinforcing delusions.

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Correct Answer is ["A","B","E","F"]

Explanation

A. Clonazepam is a benzodiazepine used primarily for anxiety disorders and can affect mental status, including cognition and level of alertness. Regular assessment helps monitor for any changes in mental status, such as drowsiness, confusion, or sedation, which are potential side effects of clonazepam.
B. This intervention helps maintain oral hygiene, which is important when a client is taking medications orally. Benzodiazepines like clonazepam can cause dry mouth as a side effect, which can contribute to oral hygiene issues such as increased risk of dental caries or oral infections.
C. Clonazepam itself does not directly affect calcium levels. Monitoring calcium levels is not a routine nursing intervention specifically related to clonazepam administration. This option is not appropriate in this context.
D. Clonazepam is not an opioid and does not directly interact with opioids in a way that would necessitate having an opioid agonist at the bedside. This option is not relevant for a client starting clonazepam.
E. Clonazepam can cause dizziness and impair coordination, especially when starting the medication or with dose changes. Assisting the client to the bathroom helps prevent falls and ensures safety, particularly if the client experiences dizziness or sedation.
F. Benzodiazepines like clonazepam can cause hypotension (low blood pressure), which may exacerbate upon standing (orthostatic hypotension). Screening involves checking blood pressure and heart rate in different positions (lying, sitting, standing) to detect orthostatic changes. This is important to prevent falls and other complications.

A. Wear a face mask while performing wound care. B. Instruct the family to adhere to contact precautions. C. Report any increase in the white blood cell count. D. Change the surgical dressing readily when soiled.

Correct Answer is D

Explanation

Rationale

A. Wearing a face mask is a standard precaution to protect against airborne or droplet transmission of pathogens. However, MRSA is primarily transmitted through direct contact with infected wounds or contaminated surfaces rather than through the air.

B. Contact precautions are essential for preventing the spread of MRSA. These precautions include wearing gloves and gowns when in direct contact with the client or potentially contaminated surfaces. However, this is not of immediate concern.

C. Monitoring the white blood cell count (WBC) is crucial in assessing for signs of infection, including wound infections. An increase in WBC count can indicate systemic infection or local wound infection, which might be related to MRSA. Early detection and prompt reporting allow for timely intervention, such as initiating appropriate antibiotic therapy or further wound assessment.

D. This is because maintaining a clean environment around the wound is crucial to prevent infection

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An older adult client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) to assist in bathing, is becoming increasingly agitated and stating the UAP "wants to hurt me and tie me up." Which approach should the nurse use with the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Correct Answer is ["A","B","E","F"]

Explanation

Correct Answer is D

Explanation

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