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 A

Explanation

A. Diarrhea is a common symptom of opioid withdrawal. Opioids slow down gastrointestinal motility, so when their use is discontinued, it can lead to increased peristalsis and diarrhea. This occurs due to the rebound effect of the gastrointestinal tract.
B. Opioids typically cause pupil constriction (pinpoint pupils) when they are active in the body. During withdrawal, the opposite occurs, and pupils dilate (mydriasis). However, the question asks about withdrawal symptoms, not effects of opioid use, so this would not be expected in opioid withdrawal.
C. Bradycardia, or a slow heart rate, is not typically associated with opioid withdrawal. Instead, opioid withdrawal can cause tachycardia (rapid heart rate) due to the sympathetic nervous system activation that occurs during withdrawal.
D. Hypokinesis refers to decreased movement or activity, which is not a typical symptom of opioid withdrawal. Instead, opioid withdrawal often presents with symptoms such as restlessness, agitation, and muscle aches, which are indicative of hyperactivity rather than hypokinesis.

A. Buprenorphine B. Diazepam C. Varenicline D. Rimonabant

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.

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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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