A nurse is assisting with the plan of care for a client who has dementia and often wanders in the halls at night. Which of the following Interventions should the nurse recommend including in the plan of care?

Turning off the lights in the client's room at bedtime

Limiting the client's physical activity during the day

Having the client wear incontinence briefs after dinner

Labeling the client's bathroom door

Answer and Explanation

The Correct Answer is D

A. Turning off the lights in the client's room at bedtime: Keeping the room well-lit at night can help prevent disorientation and reduce the risk of falls for clients with dementia. Turning off lights may increase confusion and make wandering more dangerous, so this is not an appropriate intervention.

B. Limiting the client's physical activity during the day: Reducing daytime activity can increase restlessness and nighttime wandering. Encouraging safe physical activity during the day helps expend energy and may improve sleep patterns, making limitation counterproductive.

C. Having the client wear incontinence briefs after dinner: While incontinence briefs can prevent accidents, they do not address the underlying cause of nighttime wandering and may contribute to agitation or discomfort if used inappropriately.

D. Labeling the client's bathroom door: Clear visual cues, such as labeled doors, help clients with dementia navigate their environment independently and safely. This intervention reduces confusion, supports orientation, and can decrease wandering behaviors.

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Correct Answer is B

Explanation

A. Assist the client with positioning for an ultrasound: Positioning for ultrasound is part of the preparation for amniocentesis, not a post-procedure intervention. After the procedure, the priority is monitoring the client for complications rather than repeating imaging unless clinically indicated.

B. Monitor the client for placental abruption: Amniocentesis carries a small risk of complications such as bleeding, cramping, or placental injury. Monitoring the client for signs of placental abruption, including vaginal bleeding, abdominal pain, and uterine tenderness, is an appropriate post-procedure action to ensure early detection and intervention.

C. Administer Rh.D immune globulin to the client: Administration of Rh.D immune globulin is indicated for Rh-negative clients to prevent isoimmunization. Since this client is Rh-positive, they do not require Rh immunoglobulin, so this action is not necessary.

D. Obtain an umbilical blood sample from the fetus: Umbilical blood sampling (cordocentesis) is a separate diagnostic procedure and is not part of routine amniocentesis. Post-procedure care focuses on maternal monitoring and fetal well-being rather than obtaining fetal blood immediately.

A. A client who is exhibiting flight of ideas B. A client who refuses to attend group therapy C. A client who is experiencing a moderate level of anxiety D. A client who is having command hallucinations

Correct Answer is D

Explanation

A. A client who is exhibiting flight of ideas: Flight of ideas indicates pressured, rapid speech and distractibility often seen in mania. While this requires monitoring and support, it does not pose an immediate risk of harm to the client or others.

B. A client who refuses to attend group therapy: Refusal to attend therapy reflects a non-urgent behavioral issue. The client’s autonomy should be respected, and interventions can be planned after more urgent concerns are addressed.

C. A client who is experiencing a moderate level of anxiety: Moderate anxiety may cause discomfort and decreased coping, but it does not typically create an immediate threat to safety. The nurse can intervene with calming techniques and support in a timely manner.

D. A client who is having command hallucinations: Command hallucinations can instruct the client to harm themselves or others, representing an immediate safety risk. The nurse should assess this client first to implement interventions that prevent potential harm and ensure safety on the unit.

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A nurse is assisting with the plan of care for a client who has dementia and often wanders in the halls at night. Which of the following Interventions should the nurse recommend including in the plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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