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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Air is heard escaping from around the mask: Escaping air indicates a poor seal, which compromises the delivery of high-concentration oxygen. A properly functioning non-rebreather mask should have a snug fit to the face, minimizing leaks and ensuring the client receives the intended oxygen concentration.
B. The flow control meter dial is at the correct setting: While setting the prescribed flow rate is necessary, the flow meter alone does not confirm that the mask or reservoir is functioning properly. The actual delivery of oxygen to the client depends on correct assembly, reservoir inflation, and mask seal.
C. The attached reservoir bag is inflated: An inflated reservoir bag indicates that oxygen is flowing into the bag and that the client will receive near 100% oxygen during inspiration. Proper inflation confirms that the one-way valves are functioning and that the mask is delivering high-concentration oxygen as intended.
D. The exhalation ports are covered during inspiration and expiration: Exhalation ports on a non-rebreather mask should remain open to allow carbon dioxide to escape while one-way valves prevent room air from entering during inspiration. Covered ports would restrict gas exchange and compromise oxygen delivery, indicating malfunction.
Correct Answer is A
Explanation
A. Refrain from using deodorant on the morning of the test: Deodorants, powders, lotions, and perfumes applied to the breast or axillary area can contain metallic particles such as aluminum. These substances may appear as radiopaque artifacts on the mammogram and mimic microcalcifications, potentially leading to false-positive findings or the need for repeat imaging.
B. Shower with an antimicrobial solution before the test: Mammography is a noninvasive radiographic procedure that does not require sterile preparation. Antimicrobial cleansing is unnecessary because there is no incision or breach of skin integrity. Routine hygiene is sufficient prior to the examination.
C. Avoid taking aspirin for 1 week prior to the test: Mammography does not involve tissue puncture or invasive sampling, so there is no increased bleeding risk associated with aspirin use. Antiplatelet medication adjustments are typically considered before invasive procedures such as biopsies, not routine imaging studies.
D. Do not eat or drink after midnight the night before the test: Fasting is not required for a mammogram because the procedure does not involve sedation or anesthesia. Clients may eat, drink, and take prescribed medications as usual prior to the appointment.
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