While a nurse is caring for a hospitalized client in the advanced stages of Alzheimer's disease, the client begins to have a catastrophic reaction to feeding himself. Which of the following should the nurse do first?
A) Remain calm and reassuring
B) Restrain the client temporarily
C) Draw the curtains to darken the room
D) Offer to feed the client
Ans: A
During a catastrophic reaction, the nurse should remain calm, minimize environmental distractions (quiet the environment), get the client's attention, and softly assure the client that he or she is safe. Give information slowly, clearly, and simply, one step at a time, letting the client know that the nurse understands the fear or other emotional response, such as anger or anxiety.
You might also like to view...
The nurse explains to the person with pneumonia in the left lung that being positioned in the "good lung down" offers the advantage of (select all that apply):
a. PaO2 rising in the good lung. b. blood flow to "bad lung" being increased. c. the dependent lung being better perfused. d. dyspnea disappearing. e. decreased hypoxia.
Which value represents the Mo of these values? 23 28 30 30 51 51 63 63 63 70 Standard Text: Record your answer rounding to the nearest whole number
What will be an ideal response?
A client, aged 42 years, seeks crisis intervention. She tells the nurse "I cannot take it anymore! It has
to stop. Last year my husband had an affair, and we do not communicate anymore. Three months ago I found a lump in my breast, and yesterday my 20-year-old daughter told me she is quitting college and moving to another state with her boyfriend.". After making the assessment that the client's nuclear family is unable to provide the client with sufficient situational support, the nurse should a. suggest that the client seek admission to the inpatient crisis unit. b. ask what other relatives or friends are available to support her. c. tell the client to be emotionally strong and to let her daughter go. d. foster insight by relating the present situation to earlier situations involving loss.
A homeless patient with serious and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication, and housing for the patient was obtained in a local shelter
After 2 weeks, which statement by the patient indicates significant improvement? a. "I am feeling safe and comfortable here. Nobody bothers me." b. "They will not let me drink. They have many rules in the shelter." c. "Those guys are always watching me. I think someone stole my shoes." d. "That shot made my arm sore. I'm not going to take any more of them."