A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Engage the client in a repetitive activity as a distraction.

Place the client in a seclusion room.

Apply wrist restraints to the client.

Administer PRN haloperidol IM to the client

Answer and Explanation

The Correct Answer is A

A. Engage the client in a repetitive activity as a distraction:

This is the correct answer. Redirecting the client's focus to a repetitive and calming activity can help distract them from the source of agitation and potentially de-escalate the situation.

B. Place the client in a seclusion room:

Seclusion should only be used in situations where it is absolutely necessary for the safety of the client or others. Placing a client with dementia in seclusion is not the first choice and should be avoided if possible.

C. Apply wrist restraints to the client:

Restraints should be a last resort and used only when there is an imminent risk of harm to the client or others. Restraints can escalate agitation and should not be the initial response.

D. Administer PRN haloperidol IM to the client:

The use of medication should be considered later in the escalation process and after other non-pharmacological interventions have been attempted. It is not the first intervention, especially when there are non-pharmacological options available.

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Correct Answer is D

Explanation

A. The client requires additional help to stand:

While needing additional help to stand is relevant information, it may be expected in Parkinson's disease due to issues with mobility and balance. It is not an immediate priority unless it signals a significant change or poses an immediate risk.

B. The client has increased difficulty dressing:

Increased difficulty dressing is a common manifestation of Parkinson's disease and is important to address but may not be as urgent as issues related to swallowing.

C. The client reports insomnia:

Insomnia is a common issue in Parkinson's disease but may not be an immediate priority unless it significantly impacts the client's overall well-being or contributes to other health concerns.

D. The client has difficulty swallowing:

This is the correct answer. Difficulty swallowing (dysphagia) in Parkinson's disease is a serious concern as it can lead to complications such as aspiration pneumonia and malnutrition. It requires prompt attention and intervention to ensure the client's safety and prevent potential complications.

Correct Answer is ["500"]

Explanation

To calculate the mL/hr for the lactated Ringer's IV infusion over 30 minutes, you can use the following formula:

Rate (mL/hr)=Volume (mL)/Time (hr)

In this case:

Rate=250 mL/ 0.5 hr

Rate=500mL/hr

Therefore, the nurse should set the IV pump to deliver 500 mL/hr for the lactated Ringer's IV infusion over 1 hour.

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A nurse in a long-term care facility is monitoring clients in the day room. A client who has dementia becomes angry and starts screaming at the nurse. Which of the following interventions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is collecting data for an interdisciplinary care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

Correct Answer is D

Explanation

A nurse is preparing to administer lactated Ringer's 250 mL IV to infuse over 30 min. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Correct Answer is ["500"]

Explanation

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