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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

The correct answer is choice B: Axillary.

Choice B rationale: The axillary site, or under the arm, is the preferred site for obtaining the temperature of a newborn. This method is safe and generally well-tolerated by infants. It carries a lower risk of injury or discomfort compared to other methods.

Choice A rationale: Rectal temperature measurement can be accurate but is more invasive and may cause discomfort or injury to the newborn. It is generally not the preferred method for routine temperature checks in newborns.

Choice C rationale: Tympanic temperature measurement, which uses the ear canal, may not be accurate for newborns due to their small ear canal size and the presence of vernix caseosa or amniotic fluid.

Choice D rationale: Oral temperature measurement is not suitable for newborns as they cannot hold the thermometer in their mouth safely or reliably. This method is more appropriate for older children and adults.

A. Acetone breath. B. Confusion. C. Polydipsia. D. Hot, dry skin.

Correct Answer is B

Explanation

Choice A rationale:

Acetone breath is a symptom of diabetic ketoacidosis (DKA), a complication of diabetes mellitus. It occurs due to the presence of ketones in the breath and is not specific to hypoglycemia. Hypoglycemia is characterized by low blood sugar levels, not elevated ketone levels.

Choice B rationale:

Confusion is a common symptom of hypoglycemia. When blood sugar levels drop significantly, the brain may not receive enough glucose to function properly, leading to confusion, dizziness, and other neurological symptoms.

Choice C rationale:

Polydipsia refers to excessive thirst and is a symptom of hyperglycemia (high blood sugar levels), not hypoglycemia. In hyperglycemic states, the body tries to eliminate excess glucose through urine, leading to increased thirst.

Choice D rationale:

Hot, dry skin is not a typical symptom of hypoglycemia. Hypoglycemia can cause diaphoresis (excessive sweating) and cool, clammy skin due to the body's stress response.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is obtaining the temperature of a newborn. Which of the following sites should the nurse use?

Correct Answer is B

Explanation

A nurse is assessing a client who has type 1 diabetes mellitus and was administered insulin lispro 1 hr ago.Which of the following manifestations indicates that the client might be experiencing hypoglycemia?

Correct Answer is B

Explanation

A nurse is caring for a client who has an implanted venous access port.Which of the following should the nurse use to access the port?

A nurse is collecting data from a client who is 18 hr postpartum. The nurse notes that the client is in the "taking-in phase of maternal adjustment. Which of the following manifestations should the nurse expect?

A nurse is preparing to administer three medications to a client who is receiving continuous enteral feeding through an NG tube.Which of the following actions is appropriate for the nurse to take?

A nurse is caring for a client who has a stool culture that is positive for Clostridium difficile. Which of the following infection control precautions should the nurse take?

A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?

A nurse is caring for a client in an acute care setting. Exhibits The client is at risk for ________ as evidences by __________. Complete the following sentence by using the list of options. Pick 2 choices.

A home health nurse is planning care for a client who has Alzheimer's disease.Which of the following actions should the nurse include in the plan of care?

A nurse is reviewing the medical records of four clients.The nurse should identify that which of the following client findings requires follow-up care?

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?