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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B) Speak in a neutral tone when addressing the client.
When creating a plan of care for a client with paranoid personality disorder who refuses to take their medication, it's essential to approach the client in a way that fosters trust and reduces anxiety. Speaking in a neutral, non-confrontational, and non-threatening tone can help build rapport and facilitate communication with the client.
The other options are not appropriate interventions:
A) Mixing medication with the client's food without their consent can be seen as a breach of trust and may worsen the client's paranoia.
C) Limiting the client's opportunities to socialize with others can lead to increased isolation and potentially exacerbate the client's paranoid tendencies.
D) Rotating staff members caring for the client may also contribute to feelings of mistrust and may not be conducive to establishing a therapeutic nurse-client relationship. Consistency in care can be more helpful for individuals with paranoid personality disorder.
Correct Answer is B
Explanation
The correct answer is choice B: Wear a surgical mask when within 0.9 m (3 feet) of the client.
Choice A rationale:
Fresh flowers are generally discouraged in hospital settings for clients with compromised immune systems due to the risk of infection from soil or water, which can harbor harmful microorganisms. However, this is not specifically related to rubella, which is an airborne virus.
Choice B rationale:
Rubella is transmitted through airborne droplets when an infected person coughs or sneezes. Wearing a surgical mask when close to the client can help prevent the spread of the virus. This is especially important to protect individuals who are pregnant or may become pregnant, as rubella can cause serious birth defects.
Choice C rationale:
Negative-airflow pressure rooms are used for clients with airborne infections, such as tuberculosis. While rubella is also airborne, the current guidelines do not require a negative pressure room for its management.
Choice D rationale:
While limiting visitors can help control the spread of infection, it is not the primary action to take for a client with rubella. The focus should be on preventing the spread through droplet transmission, which is addressed by wearing a mask and practicing good hand hygiene.
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