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 ["B","D","E"]
Explanation
Choice A reason: Feeling mildly anxious can be a normal reaction after a traumatic event and does not necessarily indicate PTSD.
Choice B reason: Emotional numbing and detachment from others are common symptoms of PTSD, reflecting an avoidance of reminders of the trauma.
Choice C reason: The timeframe of symptoms occurring specifically 2 weeks after the trauma is more indicative of acute stress disorder rather than PTSD.
Choice D reason: Reexperiencing the trauma through dreams or intrusive thoughts is a hallmark symptom of PTSD, often leading to significant distress.
Choice E reason: Hyperarousal, including being on guard and irritable, is a symptom of PTSD that involves an increased state of anxiety and heightened emotional response.
Correct Answer is ["A","B","D","E"]
Explanation
Choice A: Hyperventilation
Hyperventilation is rapid breathing that usually occurs because of anxiety or panic. This leads to low levels of carbon dioxide in your blood which causes a number of symptoms. Hyperventilation in anxiety can be a tricky thing to understand. On one hand, it can feel like you're suffocating or not getting enough air. On the other hand, hyperventilation can also cause shortness of breath, chest pain, and lightheadedness.
Choice B: Irritability
Irritability is a common symptom of Generalized Anxiety Disorder (GAD). Individuals with GAD often experience severe feelings of fear and unease and report feeling restless and irritable that interfere with the quality of their life.

Choice C: Anorexia
While there is a relationship between anxiety disorders and anorexia nervosa, anorexia is not a common symptom of Generalized Anxiety Disorder (GAD). Anorexia nervosa is a separate disorder that involves a fear of gaining weight and a distorted body image.
Choice D: Insomnia
Insomnia is highly prevalent in psychiatric disorders, and it has significant implications. The anxiety that characterizes GAD often interferes with the ability to sleep and leads to insomnia. This is not unexpected. Anxiety might be viewed as an inappropriate escalation of a response called arousal.
Choice E: Fatigue
Fatigue is a common symptom of Generalized Anxiety Disorder (GAD). Individuals with GAD may feel restless and have trouble relaxing. They may also tire easily or feel tired all the time.
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