A nurse is caring for a client who has dementia and wanders frequently. Which of the following actions should the nurse take?
Apply a motion sensor mat to the client's bed.
Move the overbed table away from the bed.
Raise all four side rails while the client is in bed.
Leave the television on in the client's room.
The Correct Answer is A
Choice A reason: Applying a motion sensor mat to the client's bed is an appropriate action to prevent wandering and alert the staff if the client tries to get out of bed.
Choice B reason: Moving the overbed table away from the bed is not an effective action to prevent wandering, as it does not restrict the client's mobility or provide any supervision.
Choice C reason: Raising all four side rails while the client is in bed is an inappropriate action that can increase the risk of injury or entrapment if the client attempts to climb over them.
Choice D reason: Leaving the television on in the client's room is not an effective action to prevent wandering, as it does not provide any stimulation or distraction for the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: This is incorrect because Sims position is used for clients who have lower back pain, abdominal surgery, or enemas. It is not appropriate for clients who have a closed head injury.
Choice B: This is incorrect because modified Trendelenburg position is used for clients who have hypovolemic shock or poor venous return. It is not appropriate for clients who have a closed head injury.
Choice C: This is correct because semi-Fowler's position is used for clients who have increased intracranial pressure, respiratory distress, or head trauma. It elevates the head and chest to reduce cerebral edema and facilitate breathing.
Choice D: This is incorrect because prone position is used for clients who have acute respiratory distress syndrome, spinal cord injury, or pressure ulcers. It is not appropriate for clients who have a closed head injury.
Correct Answer is D
Explanation
Choice A reason: Maintaining the client on bed rest is not an appropriate action, as it can increase the risk of thromboembolism, infection, or atelectasis after surgery. The nurse should encourage early ambulation and exercise as tolerated by the client.
Choice B reason: Decreasing the client's fluid intake is not an appropriate action, as it can cause dehydration, constipation, or impaired wound healing after surgery. The nurse should encourage adequate hydration and nutrition to promote recovery and drainage.
Choice C reason: Applying cold compresses to the site is not an appropriate action, as it can cause vasoconstriction, inflammation, or pain at the site. The nurse should apply warm compresses to the site to facilitate drainage and reduce swelling.
Choice D reason: Placing the right leg in a dependent position is an appropriate action, as it can promote gravity-assisted drainage from the site and prevent fluid accumulation or infection. The nurse should place the drain below the level of the wound and secure it to prevent dislodgment or tension.
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