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 D
Explanation
This action indicates that the charge nurse should intervene because adding food coloring to the tube feeding is not recommended and can cause adverse effects such as aspiration, diarrhea, and allergic reactions.
Choice A is wrong because checking the volume of the aspirate is a correct action to assess gastric residual volume and prevent complications such as nausea, vomiting, and aspiration.
Choice B is wrong because checking the pH of the aspirate is a correct action to verify the placement of the NG tube and prevent accidental administration of enteral feeding into the lungs.
Choice C is wrong because administering 15 mL of water before administering the feeding is a correct action to flush the NG tube and prevent clogging.
Normal ranges for gastric residual volume are less than 250 mL for adults and less than 5 mL/kg for children. Normal ranges for pH of gastric aspirate are less than 5.5 for adults and less than 4 for children.
Correct Answer is D
Explanation
The nurse should offer the client a milkshake because it is a high-calorie, high- protein, and easy-to-consume food that can meet the nutritional needs of a client who is in the manic phase of bipolar disorder. Clients who are manic often have increased activity, decreased appetite, and poor attention span, which can lead to weight loss and malnutrition.
Choice A is wrong because Creamed corn is wrong because it is a low-protein, high-carbohydrate food that can increase blood glucose levels and cause mood swings.
Choice B is wrong because Mashed potatoes is wrong because it is a low-protein, high-starch food that can also affect blood glucose levels and mood stability.
Choice C is wrong because Spaghetti with meat sauce is wrong because it is a complex food that requires utensils and attention to eat, which can be difficult for a client who is manic and distractible.
Normal ranges for potassium are 3.5 to 5.0 mEq/L.
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