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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A rationale:

The nurse should instruct the client to sleep with an extra pillow under their head. This position, known as the semi-Fowler's position, elevates the upper body and head, which can help reduce shortness of breath and difficulty breathing while lying down at night. Propranolol, a non-selective beta-blocker, can cause bronchoconstriction in some individuals, especially those with a history of respiratory issues. Elevating the head can assist in improving lung expansion and reducing the sensation of breathlessness.

Choice B rationale:

Sleeping on their left side would not be the best option in this case. While sleeping on the left side is often recommended for individuals with certain cardiac conditions to improve blood flow and reduce pressure on the heart, it may not be as effective for alleviating the respiratory symptoms caused by propranolol. Elevating the head is a more appropriate intervention in this scenario.

Choice C rationale:

Sleeping on their right side is not the ideal choice either. While it can have benefits for individuals with certain cardiac conditions, it does not address the specific respiratory symptoms reported by the client. Elevating the head is a more targeted intervention to alleviate breathlessness associated with propranolol.

Choice D rationale:

Sleeping on their back may worsen the client's symptoms. Lying flat on the back can lead to increased pressure on the diaphragm, making it more challenging to breathe for individuals experiencing shortness of breath. Therefore, it is not the recommended position for this client.

A. Procure platelet products from the blood bank. B. Titrate oxygen to the prescribed parameters. C. Monitor an intravenous infusion rate on an established schedule. D. Insert a urinary catheter for an uncomplicated client.

Correct Answer is C

Explanation

Choice A rationale:

Procuring platelet products from the blood bank is a task that should be performed by a licensed nurse, not an unlicensed assistive personnel (UAP). It involves assessing the client's needs, verifying orders, and administering the product, which require nursing judgment and skills.

Choice B rationale:

Titrating oxygen to prescribed parameters is a nursing task that requires clinical judgment, especially if the client's condition changes. UAPs do not have the training or scope of practice to adjust oxygen levels. This task should be assigned to a licensed nurse.

Choice D rationale:

Inserting a urinary catheter, even for an uncomplicated client, is a task that should be performed by a licensed nurse. It involves the potential risk of infection and injury, and it requires sterile technique and assessment of the client's condition. UAPs do not have the training or scope of practice to insert urinary catheters.

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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?​​​​​​

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who has been prescribed propranolol for the treatment of arrhythmias reports experiencing shortness of breath and difficulty breathing while lying down at night. Which of the following should the nurse instruct the client to do?

Correct Answer is A

Explanation

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is C

Explanation

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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?