A nurse is changing an abdominal dressing on a disoriented 89-year-old man when he grabs the nurse's breast muttering something about "Mary" (his wife). What is the most therapeutic re-sponse by the nurse?
a. Stereotype him as a "dirty old man" and warn the rest of the staff to stay away from him.
b. Get a physician's order for wrist restraints when nurses go near the patient for activi-ties such as dressings, baths, and feedings.
c. Maintain eye contact with the patient and then clearly tell him and repeat, "I am your nurse. I am coming to help you eat, bathe, and change your stomach bandage. I am not Mary."
d. "That dressing needs changing. Don't be a naughty boy with me again or I will slap your hands and call Mary to come and do all your care herself!"
C
Older, confused patients frequently confuse the nurse with close relations such as a spouse, whom they are accustomed to touching. Nurses should provide understanding and maintain a therapeutic environment.
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