Six hours after a client lost control and required seclusion and ...

[nenivikky]

Six hours after a client lost control and required seclusion and as-needed medication, she is out of
  seclusion, calm, and sitting in her room reading.
 
  Postassaultive stage care measures that should be
  taken by the nurse include (more than one option may be chosen)
  A. avoiding mention of the incident.
  B. suggesting that the client may wish to apologize.
  C. helping the client identify the precipitating event.
  D. reviewing possible alternative coping strategies with client.

Question 2

A nursing home resident, aged 78 years, who is being treated for hypertension and cardiac disease is
  usually alert and well oriented.
 
  This morning she tells the nurse that her granddaughter came to visit
  her during the night and stood at the foot of the bed talking to her. In reality, the client's
  granddaughter is a nurse who lives 50 miles away. The client does consider this night visit a bit
  strange but shrugs the strangeness off. The nurse should suspect that the resident may
  a. have cognitive impairment because of a high blood level of a medication.
  b. have had a ministroke and developed sensory perceptual alteration.
  c. be developing Alzheimer's disease associated with advanced age.
  d. have alcohol-related cognitive impairment.

[matt]

Answer to Question 1

C, D
Rationale: Postincident processing should be attempted when the client is calm. This processing
helps the client and staff understand what happened and how further incidents of violence can be
avoided. Identification of the precipitating event is critical. Once this is accomplished, the client and
nurse can discuss possible alternative coping strategies and role play those chosen. Options A and B
do nothing to help the client learn more effective coping strategies.

Answer to Question 2

A
A resident taking medications is at high risk for becoming confused because of medication side
effects, drug interactions, and delayed excretion. The nurse should report the event and continue to
assess for cognitive impairment. Option B: Residual impairment would probably continue to be
present in the event of a vascular event. Option C: Symptoms of dementia tend to develop slowly but
persist over time. Option D: The history would alert the nurse to alcohol-related cognitive
impairment.

[nenivikky]

Thank you

[matt]

Happy to help you