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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is a manifestation of a fat embolism, which is a condition where particles of fat get into the bloodstream and block blood flow. A fat embolism can occur after trauma or surgery to the legs, when fat from the bone marrow escapes into the bloodstream.
Choice A is wrong because a report of pain as 6 on a scale of 0 to 10 is not specific to a fat embolism.
Pain is a common symptom of many conditions and injuries.
Choice B is wrong because pulses 2+ distal to the client’s fracture are normal and indicate adequate blood flow to the extremity.
Choice D is wrong because bruising around the fracture site is an expected finding after a compound fracture and does not indicate a fat embolism.
Normal ranges for blood pressure are 90/60 mmHg to 120/80 mmHg and for heart rate are 60 to 100 beats per minute.
Petechiae are small red or purple spots on the skin caused by bleeding under the skin.
They can range in size from pinpoint to several millimeters. Fat embolism syndrome (FES) is a serious complication of a fat embolism that affects the lungs, skin or brain and can be fatal. FES usually occurs 12 to 72 hours after trauma.
Correct Answer is C
Explanation
The correct answer is choice C. Allergy to gelatin is a contraindication for the inactivated influenza vaccine because gelatin is one of the ingredients in the vaccine. People with severe, life-threatening allergies to any ingredient in a flu vaccine (other than egg proteins) should not get that vaccine.
Choice A is wrong because pregnancy is not a contraindication for the inactivated influenza vaccine. In fact, pregnant people are recommended to get a flu shot because they are at higher risk of developing serious flu complications.
Choice B is wrong because immunosuppression is not a contraindication for the inactivated influenza vaccine. People with weakened immune systems can get a flu shot, but they should avoid the nasal spray flu vaccine which contains live viruses.
Choice D is wrong because moderate illness with fever is not a contraindication for the inactivated influenza vaccine. People who are moderately ill can still get a flu shot, but they should wait until they recover if they have a severe illness.
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