The nurse is caring for a client with dementia. Which intervention is most likely to reduce agitation in this client?

Correct Answer: A

Rationale: The correct answer is A: Provide a calm environment with minimal stimulation. This intervention is most likely to reduce agitation in a client with dementia because excessive stimulation can overwhelm and confuse them, leading to increased agitation. By creating a calm environment with minimal stimuli, the client can feel more relaxed and less agitated. Summary: B: Increasing social activities may actually worsen agitation as it can be overwhelming for a client with dementia. C: While social engagement is important, too many visitors can increase agitation. D: Providing a variety of activities may lead to confusion and frustration instead of reducing agitation.

Correct Answer: D

Rationale: The correct answer is D: Review of systems. In this case, the information provided pertains to specific symptoms related to the cardiovascular system. The review of systems involves asking about symptoms in various body systems to identify any potential issues. This information helps in identifying any underlying health concerns that the patient may not have mentioned as their main complaint. Summary of why other choices are incorrect: A: Chief complaint - This is the main reason for the patient's visit or primary concern, not a list of symptoms. B: Present illness - Focuses on the details of the current medical issue, not a general review of symptoms. C: Personal and social history - Pertains to the patient's lifestyle, habits, and social support, not specific symptoms related to body systems.

Correct Answer: C

Rationale: The correct answer is C because tenderness in the right upper quadrant with inspiration points towards Murphy's sign, indicative of cholecystitis. This sign is elicited by palpating the right upper quadrant while the patient takes a deep breath. This maneuver causes the gallbladder to descend and come into contact with the inflamed peritoneum, reproducing pain and halting inspiration. Choices A, B, and D do not describe physical examination findings specific to cholecystitis such as Murphy's sign or tenderness in the right upper quadrant with inspiration. Therefore, they are incorrect.

Correct Answer: C

Rationale: Facilitation involves using verbal and nonverbal cues to encourage the patient to continue talking. In this scenario, saying "Go on" and "Mm-hmm" indicates active listening and prompts Mr. W. to elaborate on his symptoms. This technique helps gather more information and shows empathy without imposing personal assumptions or judgments. Echoing involves repeating the patient's last words, nonverbal communication refers to gestures and body language, and an empathic response involves acknowledging and validating the patient's feelings. In this case, the best fit is facilitation as it encourages further discussion without interrupting or steering the conversation.

Correct Answer: B

Rationale: The correct answer is B: Empathy. By acknowledging the patient's emotional experience and showing understanding of her feelings, the response demonstrates empathy. This response validates the patient's emotions and fosters a sense of connection and understanding. Choice A: Reassurance implies providing comfort or support, but in this scenario, the focus is on acknowledging the patient's feelings rather than providing reassurance. Choice C: Summarization involves restating key points or information, which is not demonstrated in the given scenario where the focus is on acknowledging the patient's emotional experience. Choice D: Validation involves recognizing and affirming the patient's emotions as legitimate, which aligns closely with empathy. However, in this specific scenario, the response does not explicitly confirm the validity of the patient's emotions, making it less appropriate than the answer choice of empathy.