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 B
Explanation
The indirect Coombs test is used to detect antibodies against foreign red blood cells in the maternal serum. This test can help identify maternal-fetal blood incompatibility, which can cause hemolytic disease of the newborn.
Choice A is wrong because homocysteine is a type of amino acid and is not related to blood compatibility.
Choice C is incorrect because erythropoietin is a hormone that regulates red blood cell production and is not a specific test for detecting maternal-fetal blood incompatibility.
Choice D is not the correct answer as aPTT (activated partial thromboplastin time) is a test used to evaluate blood clotting factors and is not directly related to monitoring maternal-fetal blood incompatibility.
Correct Answer is C
Explanation
Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.
Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.
Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.
Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.
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