A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

Place the client in a room close to the nurses' station.

Request a consult with recreational therapy.

Lower the window shade in the client's room.

Obtain a PRN prescription for a vest restraint.

Answer and Explanation

The Correct Answer is A

A.   This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B.   Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C.   Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D.   The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

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Correct Answer is B

Explanation

A. Buprenorphine is primarily used for the treatment of opioid dependence, not alcohol detoxification. It is a partial opioid agonist and can precipitate withdrawal symptoms in individuals dependent on opioids. Therefore, it is not appropriate for alcohol detoxification and would not typically be administered in this context.
B. Diazepam belongs to the benzodiazepine class of medications and is commonly used during alcohol detoxification. Benzodiazepines help manage symptoms of alcohol withdrawal, including anxiety, tremors, agitation, and seizures. They work by enhancing the effects of gamma-aminobutyric acid (GABA), which is an inhibitory neurotransmitter in the brain. Diazepam has a longer duration of action and is preferred in managing alcohol withdrawal due to its smoother pharmacokinetic profile compared to shorter-acting benzodiazepines.
C. Varenicline is a medication used for smoking cessation. It works by partially activating nicotine receptors in the brain, reducing the pleasurable effects of smoking and decreasing withdrawal symptoms. It is not indicated for alcohol detoxification and would not be used in this context.
D. Rimonabant is a cannabinoid receptor antagonist that was once used for weight loss but has been withdrawn from the market due to psychiatric side effects, including depression and anxiety. It is not indicated for alcohol detoxification and would not be administered in this context.

A. Providing opportunities for nutrition and toileting B. Observing range of motion of client's extremities C. Observation of the client once per hour D. Attempts at less restrictive interventions E. Names of staff members caring for the client

Correct Answer is ["A","B","D","E"]

Explanation

A. It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B. Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C. observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D. Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E. It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.

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A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

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