30. While waiting to be seen in an emergency department (ED) for possible CHF, an elderly client with moderate dementia jumps up and says, "I have to go feed my chickens now." A triage nurse's most appropriate response is:
30. While waiting to be seen in an emergency department (ED) for possible CHF, an elderly client with moderate dementia jumps up and says, "I have to go feed my chickens now." A triage nurse's most appropriate response is:
. "All right, you may leave."
. "Please tell us about your chickens."
. "That noise was the TV, not chickens."
. "You are not on the farm anymore."
Test-Taking Tip
Select an option that engages the client without attempting to orient the client with dementia.
Content Area: Geriatrics, Neurological; Integrated Process: Communication and Documentation; Cognitive Level: Analysis; Client Need/Subneed: Psychosocial Integrity/Therapeutic Communications
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Answer 1 is incorrect because the client needs to be seen in the ED. Engage the client in conversation, which will hopefully have a calming effect. Answer 2 is correct because, unlike techniques used with the client who is mentally ill, the nurse would not attempt to orient the client with moderate or severe dementia to person, place, or thing. Answer 3 is incorrect because the client with moderate dementia usually cannot be oriented to person, place, or thing. Answer 4 is incorrect because the client with moderate dementia usually cannot be oriented to person, place, or thing.