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","C","F"]
Explanation
Choice A rationale:
Urticaria is a skin condition characterized by the sudden appearance of raised, itchy, and red welts on the skin. It is an objective finding because it can be observed and assessed visually. The presence of urticaria may indicate an allergic reaction or another underlying condition.
Choice B rationale:
Hypertension is a subjective finding because it cannot be directly observed. It requires blood pressure measurement to confirm, making it a subjective parameter.
Choice C rationale:
Diaphoresis refers to excessive sweating, which can be observed and assessed visually. It is an objective finding and may be indicative of various conditions, including anxiety or fever.
Choice D rationale:
Nausea is a subjective symptom because it is a sensation that the client experiences and reports. It cannot be directly observed by the nurse, making it a subjective parameter.
Choice E rationale:
Anxiety is a subjective symptom, as it is a mental and emotional state experienced by the client. It cannot be directly observed, making it a subjective parameter.
Choice F rationale:
Edema is an objective finding because it can be visually assessed by the nurse. Edema is the accumulation of excess fluid in body tissues, and its presence or absence can be objectively determined.
Correct Answer is A
Explanation
Choice A rationale:
The client's statement, "I should avoid foods that are high in vitamin K," indicates an understanding of the medication. Warfarin is an anticoagulant medication that works by inhibiting vitamin K-dependent clotting factors. Consistent intake of vitamin K-containing foods helps maintain a stable INR (International Normalized Ratio) and warfarin's effectiveness. Clients on warfarin should be educated about avoiding drastic changes in their vitamin K intake.
Choice B rationale:
Taking warfarin with food or on an empty stomach doesn't significantly impact its efficacy. Therefore, this statement is not indicative of the client's understanding of the medication.
Choice C rationale:
The statement "I should report any unusual bleeding or bruising to my provider" is important but doesn't specifically reflect an understanding of warfarin. It's a general caution for anyone taking anticoagulants.
Choice D rationale:
While it's important to avoid excessive use of medications like aspirin that can increase the risk of bleeding, this statement doesn't directly demonstrate an understanding of warfarin itself.
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