A nurse is caring for a client who has dementia and is at risk for falls. Which of the following preventive measures should the nurse take?
Place the client’s bed in the low position.
Encourage the client to wear socks when ambulating.
Position the client’s bedside table at the foot of the bed.
Raise four side rails on the client’s bed.
The Correct Answer is A
This is because lowering the bed reduces the risk of injury if the client falls out of the bed. It also makes it easier for the client to get in and out of the bed safely.
Choice B is wrong because wearing socks when ambulating can increase the risk of slipping and falling. The client should wear shoes or slippers with non-skid soles.
Choice C is wrong because positioning the client’s bedside table at the foot of the bed can create an obstacle for the client to walk around. The bedside table should be placed near the head of the bed and within reach of the client.
Choice D is wrong because raising four side rails on the client’s bed can be considered a form of restraint and can increase the risk of injury if the client tries to climb over them. The use of restraints should be avoided for clients with dementia, as they can cause agitation, confusion, and distress. Instead, other measures such as bed alarms, motion sensors, or frequent monitoring should be used to prevent falls.
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Related Questions
Correct Answer is B
Explanation
Prepare the client for a cesarean birth.
This is because the client has herpes simplex virus with active lesions, which can be transmitted to the newborn during vaginal delivery and cause serious complications such as neonatal herpes infection. A cesarean birth can prevent this transmission and protect the newborn’s health.
Choice A is wrong because an amnioinfusion is a procedure that involves infusing fluid into the amniotic cavity to increase the volume of amniotic fluid and reduce cord compression.
It is not indicated for a client with herpes simplex virus with active lesions.
Choice C is wrong because ampicillin is an antibiotic that is used to treat bacterial infections, not viral infections such as herpes simplex virus.
Ampicillin will not prevent the transmission of herpes simplex virus to the newborn.
Choice D is wrong because oxytocin is a hormone that stimulates uterine contractions and can be used to augment or induce labor.
It is not indicated for a client with herpes simplex virus with active lesions, as it can increase the risk of transmission to the newborn by prolonging the exposure to infected genital secretions.
Correct Answer is B
Explanation
Moist heat can help reduce pain and stiffness in the joints by increasing blood flow and relaxing the muscles. Moist heat can be applied using warm compresses, heating pads, or warm baths.
Choice A is wrong because using a recliner when sitting for long periods can increase pressure on the knees and decrease circulation. A better option is to use a straight-backed chair with a footstool.
Choice C is wrong because sleeping on a soft mattress can cause poor alignment of the spine and joints, which can worsen pain and mobility. A firm mattress is recommended for clients with osteoarthritis.
Choice D is wrong because placing large pillows under the knees when lying in bed can limit the range of motion of the knees and cause contractures. A small pillow under the knees can provide some support and comfort, but it should not be too large or too high.
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