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 D

Explanation

The correct answer is choiced. Notify your healthcare provider if you start having abdominal pain.

Choice A rationale:

Exenatide does not act in the same way as insulin. It is a GLP-1 receptor agonist that enhances glucose-dependent insulin secretion, suppresses glucagon secretion, and slows gastric emptying.

Choice B rationale:

Exenatide should be injected within 60 minutes before the morning and evening meals, not within 30 minutes before or after a meal.

Choice C rationale:

There are precautions about taking exenatide with other medications. It can affect the absorption of oral medications, so timing and interactions need to be considered.

Choice D rationale:

Abdominal pain can be a sign of pancreatitis, a serious side effect of exenatide.It is important to notify the healthcare provider if this symptom occurs.

A. Refer client to the social worker for support therapy. B. Encourage client to implement relaxation techniques. C. Leave the client's room and return later in the day. D. Explain that insulin is a life-saving drug for the client. E. Explain that insulin is a life-saving drug for the client.

Correct Answer is C

Explanation

Choice A rationale:

Referring the client to a social worker for support therapy may be premature at this stage. The client's initial reaction may be due to fear or anxiety about the diagnosis and self-administration of insulin. Pushing the client into therapy without assessing their readiness may not be appropriate.

Choice B rationale:

Encouraging the client to implement relaxation techniques assumes that the client is open to learning and just needs help with anxiety management. However, the client's refusal to have the nurse in the room suggests that they are not currently receptive to teaching. It's important to address the client's emotional state first.

Choice C rationale:

Leaving the client's room and returning later in the day is the most appropriate initial action. The client's loud refusal indicates a need for privacy and emotional space. By respecting the client's wishes and revisiting the teaching later, the nurse can establish trust and build a better rapport.

Choice D rationale:

Explaining that insulin is a life-saving drug is informative but may not be effective in this situation, as the client has already requested the nurse to leave the room. Providing information about the importance of insulin should come after establishing a therapeutic nurse-client relationship.

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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

The nurse is planning discharge instructions for a client with type 2 diabetes who will be starting exenatide. Which information should be included in the discharge instructions?

Correct Answer is D

Explanation

When the nurse attempts to teach self-administration of insulin injections to a client who is newly diagnosed with type 1 diabetes mellitus (DM), the client tells the nurse in a loud voice to leave the room. Which action should the nurse take?

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?