The nurse is caring for an older adult client with Alzheimer's disease who becomes increasingly agitated and is speaking to someone who is not visible to the nurse. Which action should the nurse implement?
Reduce the client's interaction with others during the day.
Awaken the client for reality checks every 4 hours at night.
Clarify reality with the client about delusional thoughts.
Use distraction and therapeutic communication skills.
The Correct Answer is D
Choice A reason: Reducing the client's interaction with others during the day can potentially isolate the client and exacerbate feelings of agitation and confusion. Social interaction is important for cognitive stimulation and emotional well-being, even for clients with Alzheimer's disease.
Choice B reason: Awaking the client for reality checks every 4 hours at night can disrupt the client's sleep pattern, leading to increased agitation and confusion. Proper rest is crucial for clients with Alzheimer's disease to help manage their symptoms effectively.
Choice C reason: Clarifying reality with the client about delusional thoughts can sometimes increase agitation if not done sensitively. Clients with Alzheimer's disease may not respond well to direct confrontation about their delusions. It is often more effective to use techniques that do not directly challenge their perception of reality.
Choice D reason: Using distraction and therapeutic communication skills is the best approach. This strategy helps redirect the client's attention to a different, more calming activity, which can reduce agitation. Therapeutic communication involves understanding and validating the client's feelings while gently guiding them towards a more positive state. This approach respects the client's experience and provides support without escalating their agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Joining a group weight loss program is important for the client's overall health, particularly due to obesity being a significant risk factor for gallbladder disease. Weight loss can help decrease the likelihood of gallstone formation and other gallbladder-related issues. Participation in a weight loss program can also provide support and structured guidance for achieving a healthier weight.
Choice B reason: Beginning a smoking cessation class is beneficial for the client's health, as smoking is a risk factor for many diseases, including gallbladder issues. However, in the context of reducing gallbladder disease risk, weight loss would have a more direct and immediate impact, making it the primary focus for intervention.
Choice C reason: Considering hormone replacement therapy may be relevant for managing symptoms associated with menopause. However, it is not directly related to the risk reduction for gallbladder disease. Hormone replacement therapy should be discussed with a healthcare provider to weigh the benefits and risks.
Choice D reason: Scheduling rest periods after eating is generally helpful for digestion and comfort, but it does not directly address the key risk factors for gallbladder disease in this client, such as obesity and diet. Addressing these primary risk factors through weight loss would be more effective in reducing the client's risk.
Correct Answer is D
Explanation
Choice A reason: Gaining weight over six months can affect overall health and potentially exacerbate asthma symptoms by increasing the workload on the respiratory system. However, it is not an immediate trigger for asthma exacerbation.
Choice B reason: A family member contracting viral influenza poses a risk of the client catching the virus, which can exacerbate asthma. However, it is not a direct trigger of the asthma exacerbation unless the client actually contracts the virus.
Choice C reason: A family history of lung disease can indicate a genetic predisposition to respiratory issues, but it is not an immediate trigger for an asthma exacerbation.
Choice D reason: Cleaning with household supplies is a significant trigger for asthma exacerbation. Many cleaning products contain strong chemicals that can irritate the airways and provoke an asthma attack. This is the most immediate and direct cause of the client's asthma complications among the given options.
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