A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client?

Hallways are long distances

The room has an area rug

The bed is in a low position

Outside doors have locks

Answer and Explanation

The Correct Answer is A

A. Hallways are long distances:
Long hallways can be challenging for individuals with dementia due to their potential mobility issues, disorientation, and decreased ability to navigate. Dementia often affects spatial awareness and can lead to confusion, making it difficult for patients to find their way back to their rooms or common areas. Long distances increase the risk of falls and disorientation.

B. The room has an area rug:
Area rugs can present tripping hazards for anyone, especially for individuals with mobility issues, balance problems, or cognitive impairments like dementia. Patients might trip on the edges of the rug, leading to falls and injuries.

C. The bed is in the low position:
Having the bed in a low position is generally considered a safety measure, especially for patients at risk of falls. However, for a patient with dementia, it might be important to strike a balance. Beds that are too low can be difficult for individuals with dementia to get in and out of, potentially leading to falls. It's important to assess the patient's ability to safely get in and out of bed.

D. Outside doors have locks:
Locks on outside doors are essential for the safety of individuals with dementia. Dementia patients are prone to wandering, which can lead them to dangerous situations if they leave the facility unsupervised. Locks on outside doors help prevent wandering, ensuring the patients stay within the secure confines of the facility.

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Correct Answer is C

Explanation

A. Request that the client's partner sign the consent form:
While involving the client's partner might offer emotional support and facilitate communication, legal and ethical guidelines typically require the informed consent of the individual undergoing the procedure. Having a partner sign the form without the client's explicit consent would not adhere to these standards.

B. Inform the client about the risks of refusing ECT:
Educating the client about the potential risks and benefits of ECT, as well as discussing alternative treatments, is a crucial step in the informed consent process. However, merely informing the client does not replace the need for the client to provide explicit, written consent for the procedure to be performed legally and ethically.

C. Cancel the scheduled ECT procedure:
This is the correct action. Without the client's signed consent, the procedure cannot proceed. Canceling the ECT procedure respects the client's autonomy and adheres to legal and ethical standards surrounding informed consent. The healthcare team should continue to engage with the client, addressing any concerns and questions, to obtain their informed and voluntary consent before rescheduling the procedure if the client chooses to proceed.

D. Proceed with preparation for ECT based on implied consent:
Implied consent is not sufficient for significant medical procedures such as ECT. Implied consent implies agreement based on actions or behavior rather than explicit, informed agreement. For procedures like ECT, it is essential to have documented, explicit, and voluntary consent from the client before proceeding. Relying solely on implied consent would not meet the ethical and legal requirements for informed consent.

A. Clients who are involuntarily committed do not maintain access to legal counsel. B. Clients must be informed of the risks of treatment. C. Clients who have a severe mental illness cannot request a psychiatric advance directive. D. Clients who are violent can refuse chemical restraint.

Correct Answer is B

Explanation

A. Clients who are involuntarily committed do not maintain access to legal counsel.
This statement is incorrect. Clients who are involuntarily committed generally do have the right to legal counsel. They can challenge their commitment in a court of law, and legal representation is often provided to them if they cannot afford it.

B. Clients must be informed of the risks of treatment.
This statement is correct. Informed consent is a fundamental principle in healthcare, including mental health treatment. Clients have the right to be fully informed about the risks and benefits of any treatment or procedure before giving consent.

C. Clients who have a severe mental illness cannot request a psychiatric advance directive.
This statement is incorrect. Clients with severe mental illness can, and should, create psychiatric advance directives. These directives allow individuals to specify their preferences regarding mental health treatment in advance, ensuring their wishes are respected even if they are not able to communicate them at a later time due to their mental condition.

D. Clients who are violent can refuse chemical restraint.
This statement is generally incorrect. In emergency situations where a client poses an immediate danger to themselves or others, chemical restraint might be administered without the client's consent to ensure safety. However, there are strict guidelines and regulations surrounding the use of chemical restraints, and they should only be used in specific situations and as a last resort. In non-emergency situations, clients generally have the right to refuse any treatment, including chemical restraint, unless it is court-ordered due to their condition posing an imminent risk.

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A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client?

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