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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Paranoia:
Paranoia involves unfounded beliefs that others are plotting against, persecuting, or harming the individual. It is not directly related to the client's statement about bodily sensations.
B. A somatic delusion:
This is the correct choice. A somatic delusion is a false belief related to the body. In this case, the client believes that their heart exploded and blood is draining out, which is a somatic delusion involving bodily functions and sensations.
C. Concrete thinking:
Concrete thinking refers to a literal and straightforward way of thinking without the ability to interpret abstract or metaphorical language. While the client's statement is literal, it is not an example of concrete thinking. Concrete thinking would involve an inability to understand figurative language, which is not the case here.
D. A visual hallucination:
Visual hallucinations involve seeing things that are not present. The client's statement does not describe a visual experience but rather a false belief about bodily sensations, indicating a somatic delusion.
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.
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