A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?
Place the client in a seclusion room.
Engage the client in a repetitive activity as a distraction.
Administer PRN haloperidol IM to the client.
Apply wrist restraints to the client.
The Correct Answer is B
A. Seclusion is a highly restrictive intervention and is not the first action for managing agitation in dementia clients.
B. Engaging the client in a repetitive activity as a distraction is the least restrictive intervention and can help calm the client by redirecting their attention. Non-pharmacological and less restrictive approaches are preferred as initial responses to manage agitation in dementia clients.
C. Administering PRN haloperidol IM is a pharmacological intervention and should be reserved for situations where less restrictive measures have failed.
D. Applying wrist restraints is a restrictive intervention that can increase agitation and is not appropriate as a first-line approach.
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Correct Answer is A
Explanation
A. Respecting the daughter's decision to refuse the transfusion aligns with the principles of patient autonomy and the authority granted through the durable power of attorney for health care, meaning the daughter's wishes must be followed.
B. Encouraging the daughter to allow the transfusion would undermine her role as the decision-maker and may cause unnecessary conflict, making this option inappropriate.
C. Discussing guardianship is not necessary or appropriate in this context, as the daughter has already been designated as the decision-maker, which negates the need for additional legal intervention.
D. Asking the provider to give consent for the transfusion contradicts the authority granted to the daughter, as she is the legally recognized decision-maker and has already made her choice.
Correct Answer is D
Explanation
A. Investigating home care services covered by insurance is not the primary focus of a nurse preparing for an interprofessional meeting.
B. Developing a nutritional teaching plan, while beneficial, is more specific to nursing care and may not require input from the entire interprofessional team.
C. Creating a collaborative plan of care is a goal of the meeting itself rather than an individual preparation task.
D. Collecting data on the client’s required assistance level provides valuable input on the client’s current functional status, enabling a more comprehensive team discussion and planning for appropriate interventions.