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:
Ask the wife to stop and assess the client's swallowing reflex. Rationale: While assessing the client's swallowing reflex is important, the immediate priority is to provide hydration and comfort to the client, especially if the client is tearful and attempting to drink water. The nurse should assist the wife in providing small sips of water while being cautious and observing the client's ability to swallow safely.
Choice B rationale:
Give the wife a straw to help facilitate the client's drinking. Rationale: Giving the wife a straw may be helpful, but it does not address the client's immediate need for hydration and assistance with drinking. The nurse should actively assist in providing water to the client while assessing the client's ability to swallow safely.
Choice C rationale:
Assist the wife and carefully give the client small sips of water. Rationale: This is the correct answer. The nurse's immediate priority should be to assist the client with hydration. Providing small sips of water while being cautious and observing the client's ability to swallow safely is an appropriate action. This can help address the client's immediate needs for comfort and hydration.
Choice D rationale:
Obtain thickening powder before providing any more fluids. Rationale: While thickening powder may be necessary for clients with swallowing difficulties, it may cause unnecessary delay in providing hydration to the client in distress. The nurse should first provide water and assess the client's swallowing abilities. If thickened liquids are indicated, they can be administered later as per the healthcare provider's orders.
Correct Answer is ["A","B"]
Explanation
Choice A rationale:
Fresh or frozen vegetables without sauce. Rationale: Fresh or frozen vegetables without sauce are excellent choices for a client with hypertension. These foods are low in sodium and can help manage blood pressure effectively. The absence of added sauces ensures that there is no hidden sodium content.
Choice B rationale:
Fruits without sauce. Rationale: Fruits without sauce are also suitable for clients with hypertension. They are naturally low in sodium and provide essential nutrients that can support blood pressure control. The absence of sauce ensures that no additional sodium is added.
Choice C rationale:
Pickled olives. Rationale: Pickled olives are high in sodium due to the pickling process. Therefore, they are not recommended for clients with hypertension as they can lead to an increase in blood pressure.
Choice D rationale:
Canned soup. Rationale: Canned soup often contains high levels of sodium, which is not suitable for clients with hypertension. Excessive sodium intake can contribute to elevated blood pressure and should be avoided.
Choice E rationale:
Cottage cheese. Rationale: Cottage cheese is generally considered acceptable for clients with hypertension, especially if it is the low-sodium or reduced-sodium variety. However, it is not as strongly recommended as fresh or frozen vegetables and fruits without sauce.
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