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
BMI 32.2.
A high body mass index (BMI) is a major risk factor for type 2 diabetes mellitus, as it indicates overweight or obesity.
Overweight or obesity can cause insulin resistance, which means the body cells do not respond well to insulin and cannot take up glucose from the blood. This leads to high blood sugar levels and diabetes.
Choice A is wrong because history of exercise-induced asthma is not a risk factor for type 2 diabetes mellitus.
Asthma is a respiratory condition that causes inflammation and narrowing of the airways, but it does not affect the metabolism of glucose or insulin.
Choice B is wrong because age 35 years is not a risk factor for type 2 diabetes mellitus.
Although the risk of diabetes increases with age, especially after 45 years, it can also occur in younger people.
Age alone is not enough to cause diabetes.
Choice C is wrong because history of mumps is not a risk factor for type 2 diabetes mellitus.
Mumps is a viral infection that affects the salivary glands, but it does not damage the pancreas or impair insulin production.
Some other risk factors for type 2 diabetes mellitus are family history, race or ethnicity, physical inactivity, prediabetes, gestational diabetes, polycystic ovarian syndrome, and smoking.
Correct Answer is B
Explanation
It occurs because nicotine stimulates the release of dopamine, a neurotransmitter that regulates mood and pleasure. When nicotine intake is stopped, dopamine levels drop and cause anxiety and irritability.
Choice A is wrong because tachycardia, or rapid heart rate, is not a symptom of nicotine withdrawal. In fact, smoking can increase blood pressure and heart rate, so quitting smoking may lower them.
Choice C is wrong because weight loss is not a symptom of nicotine withdrawal. On the contrary, weight gain is more likely to occur after quitting smoking, because nicotine suppresses appetite and increases metabolism.
Choice D is wrong because vomiting is not a symptom of nicotine withdrawal. Vomiting may be a side effect of some nicotine replacement therapies, such as patches or gum, but it is not caused by the lack of nicotine itself.
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