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 B
Explanation
Choice A rationale:
Diarrhea and flatulence are common side effects of statin medications like lovastatin but are typically not considered emergencies. They may be managed with dietary adjustments or over-the-counter remedies.
Choice B rationale:
Muscle pain, especially if severe, requires the most immediate follow-up by the nurse. Muscle pain can be a symptom of a rare but serious side effect called rhabdomyolysis, which can lead to muscle breakdown and potential kidney damage. Prompt assessment and intervention are necessary if severe muscle pain occurs.
Choice C rationale:
Altered taste is a side effect of lovastatin but is generally not considered a medical emergency. It may affect the client's quality of life but does not require immediate follow-up.
Choice D rationale:
Abdominal cramps may occur as a side effect of lovastatin, but they are not typically considered an emergency. Like choice A, abdominal cramps can often be managed with dietary adjustments or over-the-counter remedies.
Correct Answer is B
Explanation
Choice A rationale:
Assessment of tobacco use geared toward adolescents. Rationale: While assessing tobacco use is essential for promoting health in adolescents, the question is about developing a class about mental health and addressing the increase in suicides in the community. Assessing tobacco use is not directly related to this topic. Stress self-management techniques are more relevant.
Choice B rationale:
Exploration of stress self-management techniques. Rationale: This is the correct answer. Addressing stress and teaching adolescents self-management techniques is crucial in the context of mental health promotion and suicide prevention. Adolescents often face stressors, and providing them with effective strategies to manage stress can contribute to their overall well-being.
Choice C rationale:
Video with statistics showing trends in suicide rates. Rationale: While providing statistics about suicide rates can be informative, it may not be the most engaging or effective method for teaching adolescents about mental health and stress management. Interactive activities and skill-building exercises are often more beneficial.
Choice D rationale:
Handouts for local substance abuse treatment centers. Rationale: Providing handouts for substance abuse treatment centers
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.