A nurse in a long-term care facility is admitting a client who has dementia.
Which of the following actions should the nurse take to reduce the risk for client injury?

Assist the client to the toilet frequently.

Raise the side rails up when the client is in bed.

Place the bedside table at the foot of the bed.

Keep the television on during the night.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Clients with dementia often experience difficulties with memory, cognition, and orientation, which can lead to increased risk of falls and injuries, especially when trying to perform activities of daily living such as using the toilet. Assisting the client to the toilet frequently helps prevent accidents and reduces the risk of injury from falls. Timely toileting can also improve the client's comfort and overall quality of life.

Choice B rationale:

Raising the side rails up when the client is in bed can create a physical barrier, but it is not a recommended method to prevent falls in clients with dementia. In fact, it can pose a risk by confining the client and may lead to attempts to climb over the rails, resulting in falls and injuries.

Choice C rationale:

Placing the bedside table at the foot of the bed does not directly address the client's safety needs. While it might be a matter of personal preference or convenience, it does not significantly impact the client's risk of injury.

Choice D rationale:

Keeping the television on during the night does not address the client's physical safety. While it may provide entertainment or a familiar environment, it does not mitigate the risk of falls or injuries, which is the primary concern when caring for clients with dementia.

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Correct Answer is B

Explanation

The correct answer is Choice B: Assign the child to a negative air pressure room.

Choice A rationale: Assessing the child for Koplik spots is not appropriate in this situation because Koplik spots are associated with measles, not varicella. Koplik spots are small, white, irregular lesions that appear on the buccal mucosa during the prodromal phase of measles. They do not present in cases of varicella, which is characterized by a pruritic, vesicular rash.

Choice B rationale: Assigning the child to a negative air pressure room is the most suitable action because varicella is highly contagious and can be transmitted through airborne particles. A negative air pressure room helps to contain these particles and minimize the risk of infection transmission to other patients, healthcare workers, and visitors. Airborne precautions are the recommended infection control measures for managing varicella cases in healthcare settings.

Choice C rationale: Utilizing droplet precautions alone is insufficient for managing varicella because the virus can also be spread through airborne particles. While droplet precautions may be a component of the overall infection control strategy, they are inadequate without the additional implementation of airborne precautions, such as a negative air pressure room.

Choice D rationale: Administering aspirin to a child with a viral illness is generally contraindicated due to the potential risk of Reye's syndrome, a rare but severe condition characterized by liver failure and encephalopathy. It is essential to follow appropriate guidelines for managing fever and discomfort in pediatric patients with varicella, which typically involve using acetaminophen or ibuprofen instead of aspirin.

A. Lethargy. B. Diarrhea. C. Tachycardia. D. Hirsutism.

Correct Answer is A

Explanation

Lethargy is an expected finding in a child with hypothyroidism. Hypothyroidism slows down the body's metabolism, leading to fatigue, weakness, and lethargy. Children with hypothyroidism may appear sluggish and have low energy levels.

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A nurse in a long-term care facility is admitting a client who has dementia.Which of the following actions should the nurse take to reduce the risk for client injury?

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A nurse in a long-term care facility is admitting a client who has dementia.
Which of the following actions should the nurse take to reduce the risk for client injury?