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 D
Explanation
Choice A: This is incorrect because stool being a dark green color is not a finding that the nurse should report to the provider. Stool from an ileostomy can be dark green, brown, or yellow depending on the diet and fluid intake of the client.
Choice B: This is incorrect because stoma being a cherry red color is not a finding that the nurse should report to the provider. Stoma from an ileostomy should be moist and pink or red, indicating adequate blood supply and healing.
Choice C: This is incorrect because stool containing scant red blood is not a finding that the nurse should report to the provider. Stool from an ileostomy can contain small amounts of blood due to irritation or inflammation of the bowel mucosa.
Choice D: This is correct because stoma retracting into the abdominal wall is a finding that the nurse should report to the provider. Stoma from an ileostomy should protrude slightly above the skin level, allowing for proper drainage and appliance fitting. Stoma retraction can indicate ischemia, obstruction, or peritonitis.
Correct Answer is D
Explanation
Choice A reason: Prone position is not appropriate for a paracentesis, as it can compress the abdominal organs and make it difficult to access the peritoneal cavity.
Choice B reason: Knees elevated position is not appropriate for a paracentesis, as it can increase the intra-abdominal pressure and reduce the amount of fluid that can be drained.
Choice C reason: Lithotomy position is not appropriate for a paracentesis, as it can expose the genital area and increase the risk of infection or injury.
Choice D reason: Leaning forward position is appropriate for a paracentesis, as it can shift the abdominal organs upward and allow more space for the needle insertion and fluid drainage.
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