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 C

Explanation

A. A submissive personality alone is less likely to be a direct risk factor for becoming a perpetrator of child abuse. Individuals with a submissive personality tend to avoid confrontation and conflict rather than engage in aggressive or abusive behaviors towards others.
B. Being involved in community activities is generally a positive factor that promotes social engagement, support networks, and a sense of belonging. It does not inherently contribute to an increased risk of becoming a perpetrator of child abuse.
C. Low tolerance for frustration can be a risk factor for potential aggressive or impulsive behaviors. When individuals have difficulty managing frustration, they may be more prone to react impulsively or aggressively towards others, including children.

D. The absence of impulsive behaviors typically indicates better impulse control and decision-making abilities. Individuals who can regulate their impulses are less likely to engage in spontaneous or aggressive actions, including perpetrating child abuse.

A. Allow the client to choose activities for the day. B. Redirect client behavior by initiating physical exercise. C. Encourage the client to spend time with others D. Be specific when explaining care to the client.

Correct Answer is D

Explanation

A. Allowing the client to choose activities may lead to decision fatigue or overwhelm due to the manic state.
B. Initiating physical exercise could help in redirecting excess energy, but it must be carefully monitored.
C. Encouraging the client to spend time with others might increase stimulation and potentially exacerbate the mania.
D. Clarity and specificity in communication are essential when caring for a client experiencing mania. Manic episodes can affect a client's ability to concentrate and process information. Providing clear instructions and explanations helps ensure the client understands what is expected and can follow through with necessary self-care and treatment activities.

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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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