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 ["A","C","D","E"]
Explanation
Choice A: The narcotic count is incorrect when the nurse ends the shift
An incorrect narcotic count at the end of a shift is a serious issue that could indicate potential drug diversion. It's crucial for nurses to accurately count and document narcotics to ensure patient safety and maintain legal and ethical standards. Therefore, this behavior should be reported to the nurse manager.
Choice B: The nurse has poor hygiene practices and has an offensive body odor
While poor hygiene and offensive body odor can be disruptive and unpleasant in a workplace setting, they are not direct indicators of substance use disorder. However, it's important to note that changes in personal hygiene can sometimes be a sign of other health or personal issues.
Choice C: The observing nurse finds oral narcotics blister packs torn in the back
Finding torn narcotics blister packs could indicate that a nurse is diverting drugs for personal use. This is a serious violation of nursing practice and should be reported immediately.
Choice D: The clients are reporting a lack of pain control when the nurse is working
If patients consistently report a lack of pain control when a specific nurse is working, it could suggest that the nurse is not administering the prescribed pain medications properly¹?¹?¹?¹?¹?. This could be due to a variety of reasons, including potential drug diversion, and should be reported.
Choice E: The nurse administers narcotics and then goes to use the bathroom
Frequent bathroom breaks immediately after administering narcotics could be a red flag for drug diversion. While there could be other explanations, this behavior in the context of the other signs could indicate a substance use disorder and should be reported.
Correct Answer is D
Explanation
Choice A reason: Psychotic behavior is not common in postpartum depression; it is more associated with postpartum psychosis, a rare and severe form of the condition.
Choice B reason: Harming the infant is not a common manifestation of postpartum depression and is a misconception.
Choice C reason: Postpartum depression does not typically begin 48 hours after childbirth; this is more indicative of the "baby blues," which are less severe and more transient.
Choice D reason: Women with a history of depression are at a higher risk for postpartum depression, making this statement accurate.
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