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.

Answer and Explanation

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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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.

A. Warn the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination. B. Keep the facility’s security personnel constantly visible to the client throughout treatment. C. Collaborate with the client to develop a daily physical exercise routine. D. Agree that the hallucinations are real if the client exhibits aggressive behavior toward other clients.

Correct Answer is C

Explanation

Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.

Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.

Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.

Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.

The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is pregnant and Rh-negative. The nurse should plan to monitor which of the following maternal laboratory test results to determine maternal-fetal blood incompatibility?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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