The nurse is caring for a family whose older father with dementia is living in their home. The nurse has instructed the family about how to decrease the father's agitation. The nurse determines that the son has understood the nurse's instructions when he states which of the following?

Correct Answer: D

Rationale: The correct answer is D. Simplifying the home environment can reduce agitation in a person with dementia by minimizing distractions and confusion. This approach promotes a calm and safe environment for the father. Restraints (A) are not recommended as they can lead to physical and psychological harm. Placing the father in the bedroom (B) may cause feelings of isolation and worsen agitation. Taking him out shopping (C) may overstimulate and confuse him further, increasing agitation. Simplifying the home environment aligns with best practices for managing dementia-related agitation.

Correct Answer: B

Rationale: The correct answer is B because switching from prn (as-needed) pain medication to patient-controlled analgesia empowers the patient to manage their pain effectively, addressing the issue of feeling powerless and dependent on nursing staff for pain relief. This intervention also aligns with the patient's impulsivity and need for immediate gratification. Choice A is incorrect because teaching coping strategies may not address the immediate pain relief the patient desires. Choice C is incorrect as it focuses on addressing the behavior without addressing the underlying issue of pain management. Choice D is incorrect because it does not provide a solution to the immediate problem of pain control and may not be relevant to the patient's current behavior.

Correct Answer: B

Rationale: The correct answer is B because it demonstrates active listening and empathy. By acknowledging the patient's conflicting nonverbal cues, the response shows understanding and encourages further exploration of the patient's feelings. This approach helps build rapport and trust. A: This response is overly optimistic and dismisses the patient's nonverbal cues, missing an opportunity to address underlying concerns. C: This response jumps to conclusions and may come across as judgmental, potentially shutting down communication. D: This response imposes a judgment on the patient without exploring the underlying reasons for the conflicting behavior, which can be counterproductive.

Correct Answer: B

Rationale: The correct answer is B: Your child may seem unduly anxious in the presence of strangers. This response is most appropriate as it aligns with the typical behavior of young children who have experienced a traumatic event like an automobile accident. Children at this age may exhibit increased anxiety and fear when around unfamiliar individuals due to the stress and uncertainty of their situation. This behavior is a common reaction to trauma. Choice A is incorrect because while changes in appearance may impact the child, it is not the most immediate concern in this scenario. Choice C is incorrect as guilt feelings are less likely to be prominent in a 3-year-old child. Choice D is also incorrect as mood swings are not the primary behavior expected in this situation, and the statement lacks specificity compared to the appropriate response.

Correct Answer: A

Rationale: Step-by-step rationale for why choice A is correct: 1. Safety of all individuals is paramount in an inpatient setting. 2. Least restrictive intervention aligns with ethical principles and respects individual autonomy. 3. It prioritizes de-escalation techniques over coercive measures. 4. Emphasizes the importance of promoting patient dignity and minimizing harm. 5. Encourages collaborative problem-solving and empowerment of the individual. Summary of why other choices are incorrect: B. Swift intervention may escalate the crisis and disregard patient autonomy. C. Majority rule does not justify violating individual rights in a mental health setting. D. Allowing patients to regain control without intervention can pose risks to themselves and others.