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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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Apply a body shrouding is appropriate as it covers the body, maintaining privacy and dignity. It's a common practice to cover the body with a sheet or shroud to ensure modesty.

B. Removing resuscitation equipment from the room is important to remove any reminders of medical interventions and procedures, allowing the family to focus on saying goodbye to their loved one without the presence of medical equipment that may be distressing.

C. Closing the eyes of the deceased is a respectful gesture in many cultures. It can create a peaceful appearance and is often considered a final act of care.

D. Place a small pillow under the head to support the head and neck in a more natural position. It helps create a more relaxed and comfortable appearance for the deceased.

E. Removing dentures is not typically done immediately after death, as it can alter the deceased's facial appearance.

NGNS

A. Select foods that are lower in caloric density B. Increase exercise intensity C. Get up and walk at least once an hour at work D. Add healthy foods to increase caloric intake E. Avoid food with high carbohydrate levels

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A. Select foods that are lower in caloric density
Effective: Choosing foods that are lower in caloric density (such as fruits, vegetables, lean proteins) can help the client feel fuller with fewer calories. This can support weight maintenance or even weight loss if that is the goal.

B. Increase exercise intensity
Effective: Increasing exercise intensity can help the client burn more calories, contributing to energy expenditure. This can assist in achieving energy balance, particularly if the client wants to maintain her current weight while consuming adequate calories.

C. Get up and walk at least once an hour at work
Effective: Incorporating regular physical activity throughout the day, such as walking breaks, helps increase energy expenditure. It also breaks up sedentary behavior, which is beneficial for overall health and can contribute to energy balance.

D. Add healthy foods to increase caloric intake
Ineffective: Adding healthy foods to increase caloric intake would likely lead to a positive energy balance (where intake exceeds expenditure), potentially causing weight gain. Since the goal is to maintain weight, increasing caloric intake, even with healthy foods, would not be effective.

E. Avoid food with high carbohydrate levels
Ineffective: Carbohydrates are an important source of energy. Avoiding foods with high carbohydrate levels could limit the client's energy intake, potentially leading to negative energy balance if not replaced adequately with other nutrients.

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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

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

Exhibits The nurse discusses the keep to balance energy intake and output to maintain weight Click to indicate whether the following actions would be effective or ineffective for this client to achieve energy balance. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

Explanation

A client is admitted to the mental health unit for feelings of depression secondary to a positive HIV report. To provide a safe milieu for this client, which action should the nurse take?

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.

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