A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Turn on the bed alarm.

Maintain the bed in the lowest position.

Place the client in a vest restraint.

Administer a sedative.

Encourage the family to stay with the client.

Answer and Explanation

Correct Answer : A,B,E

A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.

B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.

C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.

D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.

E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.

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Correct Answer is D

Explanation

A. The client reports taking the medication 30 min before the prescribed time. Taking a medication slightly earlier is unlikely to significantly affect its therapeutic efficacy.

B. The client received an influenza vaccine 1 month ago. Vaccination does not interfere with arthritis medications unless it triggers an immune response leading to disease flare-up, which is rare.

C. The client reports taking the medication with room temperature water. The temperature of the water does not impact the drug’s effectiveness.

D. The client has a history of recurring bowel inflammation. Chronic bowel inflammation (e.g., Crohn’s disease) can affect drug absorption, reducing medication effectiveness.

A. Client appears anxious B. Mucous membranes cyanotic C. S1, S2 auscultated, no murmur D. Skin warm and dry E. Respiratory rate 27/min F. Oxygen saturation 84% on 3L nasal cannula

Correct Answer is ["A","B","E","F"]

Explanation

Oxygen Saturation: 84% on 3L nasal cannula

The client’s oxygen saturation has dropped from 89% to 84%, indicating worsening hypoxia. In an asthma exacerbation, declining oxygen levels suggest inadequate gas exchange and potential progression to respiratory failure.

Mucous Membranes Cyanotic

Cyanosis is a late sign of hypoxia and indicates that the client is not oxygenating adequately. This suggests that bronchoconstriction and airway obstruction are worsening despite initial treatment.

Respiratory Rate: 27/min (Increased from 22/min)

An increasing respiratory rate suggests increased work of breathing. The client is attempting to compensate for worsening airway obstruction, which can lead to respiratory fatigue if not managed promptly.

Client Appears Anxious

Anxiety in this context may indicate air hunger and respiratory distress. Clients in worsening asthma exacerbations often become restless or agitated due to inadequate oxygenation.

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A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client Information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness?

Correct Answer is D

Explanation

Correct Answer is ["A","B","E","F"]

Explanation

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