The nurse is performing a history and physical assessment for a client in the clinic with moderate dementia. The client becomes agitated when asked questions and inquires why so many questions are being asked. What are the best actions for the nurse to take to obtain the necessary data? Select all that apply.
Persistently ask the same question until answered.
Give the client ample time to answer the questions asked.
Ask simple questions instead of compound questions.
Provide simple explanations to the client as often as required.
Take frequent breaks during the interview process.
Correct Answer : B,C,D,E
Choice A reason: Persistently asking the same question can increase agitation in clients with dementia.
Choice B reason: Allowing ample time for responses can reduce pressure and agitation in clients with dementia.
Choice C reason: Simple questions are easier for clients with dementia to understand and respond to.
Choice D reason: Providing simple explanations can help clients with dementia understand the purpose of the questions.
Choice E reason: Taking frequent breaks can help prevent fatigue and agitation during the assessment process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Sleeping 12 hours or more each day can be a response to various stressors, but it is not a specific or expected finding in PTSD.
Choice B reason: A constant need to talk about the event may be part of the processing of trauma, but it is not an expected finding as many individuals with PTSD may avoid discussing the traumatic event.
Choice C reason: An increasing sense of attachment to others is not typically associated with PTSD, as individuals may instead experience detachment or estrangement from others.
Choice D reason: Increasing feelings of anger are common in individuals with PTSD as they may have difficulty controlling anger and may be easily irritated.
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: A cardiac monitor is essential during ECT to monitor the heart's electrical activity, as the procedure can affect heart rate and rhythm.
Choice B reason: A blood pressure monitor is necessary to track the client's blood pressure throughout the procedure, as ECT can cause fluctuations in blood pressure.
Choice C reason: A portable x-ray machine is not typically required in the setup for ECT.
Choice D reason: An EEG monitor is used during ECT to record the electrical activity of the brain, which is crucial for assessing the seizure activity induced by the treatment.
Choice E reason: An ophthalmoscope is not used during ECT; it is an instrument for examining the interior structures of the eye.
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