An older client with dementia who is refusing to allow an unlicensed assistive personnel (UAP) bathe her is becoming increasingly agitated and stating the UAP wants to hurt her and tie her up. Which approach should the nurse use with the client?
Reduce the client's interaction with others during the day.
Use distraction and therapeutic communication skills.
Awaken the client earlier for daily morning care.
Clarify reality with the client about delusional thoughts.
The Correct Answer is B
Choice A 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 worsen the client's agitation and delusions. It does not address the client's emotional distress.
Choice B 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.
Choice C rationale:
Awakening the client earlier for daily morning care may further disrupt the client's sleep patterns and worsen agitation. It does not address the underlying issue of delusional thoughts and the client's emotional distress.
Choice D rationale:
Clarifying reality with the client about delusional thoughts can be counterproductive in dementia care. The client's cognitive impairment may make it challenging for them to understand or accept the clarification, leading to increased frustration and agitation. It is essential to use a more empathetic and therapeutic approach.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.
Choice B rationale:
Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.
Choice C rationale:
While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.
Choice D rationale:
Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.
Correct Answer is D
Explanation
Choice A rationale:
Sinus tachycardia may occur in response to various stressors or physiological conditions but is not directly related to anorexia nervosa or severe malnutrition. It is not the primary pathological process resulting from this condition.
Choice B rationale:
Menstrual cramps are not a pathological process but rather a symptom that may result from hormonal changes or other factors. While amenorrhea (absence of menstrual periods) is a common feature of anorexia nervosa, menstrual cramps are not a primary concern in this context.
Choice C rationale:
Hypertension is not typically associated with anorexia nervosa or severe malnutrition. In fact, individuals with anorexia nervosa often experience hypotension (low blood pressure) due to dehydration and nutritional deficiencies.
Choice D rationale:
Amenorrhea is the primary pathological process resulting from the adolescent's consistent maladaptive behavior of anorexia nervosa. Severe malnutrition and low body weight can disrupt the normal menstrual cycle and lead to amenorrhea. This is a significant concern for individuals with anorexia nervosa and can have long-term health implications.
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