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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Veracity involves providing accurate and truthful information to the client. By reinforcing information about potential adverse effects of a medication, the nurse ensures that the client is fully informed. This aligns with the principle of veracity because it involves transparency and honesty in discussing the potential risks associated with treatment.
B. Respecting the client's autonomy and right to make decisions about their treatment plan relates more to the ethical principle of autonomy rather than veracity. While respecting autonomy is essential, it doesn't directly address truthfulness or honesty in communication.
C. Encouraging a client to participate in a daily exercise program supports their physical well-being and can be beneficial for their recovery. However, it doesn't specifically relate to the ethical principle of veracity, which focuses on truthful communication.
D. Confidentiality is another ethical principle that pertains to protecting the client's privacy and maintaining confidentiality of their health information. While important, it doesn't directly relate to veracity, which is about honesty and truthfulness in communication with the client.
Correct Answer is D
Explanation
A. Role-playing is a useful technique to teach and reinforce new behaviors by allowing the child to practice appropriate responses in simulated situations. While role-playing can be beneficial, it is not specifically related to redirection technique. Redirection involves diverting a child's attention or behavior away from inappropriate or disruptive actions towards more acceptable behaviors.
B. Moving closer to a child who is agitated can be a strategy to provide physical proximity and support, especially to prevent escalation of behavior or to intervene if necessary. However, it is not directly related to redirection technique.
C. Ignoring attention-seeking behaviors is a common behavior management strategy aimed at reducing reinforcement of undesirable behaviors. While ignoring can be effective in some situations, it is not specifically redirection technique.
D. This statement correctly reflects the redirection technique. Redirection involves redirecting the child's focus or behavior from negative or inappropriate actions towards positive and appropriate activities or tasks. By re-engaging the child in an appropriate activity, the parent can effectively redirect their attention and energy, potentially preventing or diffusing disruptive behaviors.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
