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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Aspartate aminotransferase 20 units/L:
This result indicates the level of an enzyme in the blood. A value of 20 units/L is within the normal range (usually 10-40 units/L). Aspartate aminotransferase (AST) is an enzyme found in the liver, heart, muscles, and other tissues. Elevated levels might indicate liver damage, but 20 units/L is a normal value.

B. Platelets 250,000/mm3:
Platelets are components of blood that help with clotting. A value of 250,000/mm3 is within the normal range (normal range is typically 150,000 to 450,000/mm3). Normal platelet levels are crucial for preventing excessive bleeding or clotting.

C. Sodium 140 mEq/L:
Sodium is an electrolyte essential for maintaining the body's water balance and nerve function. A level of 140 mEq/L falls within the normal range (typically 135-145 mEq/L). Proper sodium levels are important for overall body functioning.

D. Fasting glucose 175 mg/dL:
This indicates the concentration of glucose (sugar) in the blood after a period of fasting. A level of 175 mg/dL is elevated. Fasting glucose levels above 125 mg/dL may suggest diabetes or prediabetes. Elevated glucose levels are a cause for concern as they indicate poor blood sugar regulation, which can lead to various health complications, including diabetes.

A. "I will do my best to avoid crying in front of my loved ones." B. “I will stay in bed on days when I feel exhausted." C. “I’ll use the coping mechanisms that helped me in the past." D. “I will avoid talking about events that upset me."

Correct Answer is C

Explanation

A. "I will do my best to avoid crying in front of my loved ones."
This statement suggests the client might be trying to hide their emotions, which can lead to further emotional distress. Suppressing emotions, like crying, is not a healthy coping mechanism and can exacerbate feelings of sadness and isolation.

B. “I will stay in bed on days when I feel exhausted."
Staying in bed excessively, especially during the day, is a behavior associated with depression and can worsen depressive symptoms. Encouraging the client to maintain a regular sleep schedule and engage in activities, even if they are small, is a more beneficial approach. Physical activity and exposure to natural light can positively impact mood.

C. “I’ll use the coping mechanisms that helped me in the past."
This is the correct choice. Reverting to previously effective coping mechanisms indicates an understanding of self-awareness and the ability to recognize what has worked positively in the past. Coping mechanisms such as relaxation techniques, hobbies, social support, or therapy can be valuable tools in managing depressive symptoms.

D. “I will avoid talking about events that upset me."
Avoiding discussions about upsetting events can prevent the client from addressing and processing their emotions, hindering the therapeutic process. Encouraging open communication and expressing feelings with a trusted individual, therapist, or support group can help the client work through emotional challenges.

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