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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A: This is correct because placing electrical cords against the wall can prevent tripping and falling, which can cause injury or dislocation of the hip prosthesis. The nurse should instruct the client to remove any clutter or obstacles from the floor and use assistive devices such as a walker or cane.

Choice B: This is incorrect because placing a throw rug next to the bathtub can increase the risk of slipping and falling, especially when the floor is wet. The nurse should instruct the client to avoid using throw rugs or mats and install grab bars and non-skid mats in the bathroom.

Choice C: This is incorrect because keeping pot handles turned toward the edge of the stove can cause burns or spills, which can also lead to falls or infections. The nurse should instruct the client to turn pot handles inward or use the back burners of the stove.

Choice D: This is incorrect because storing extra blankets in a box on the steps can obstruct the access to the stairs and pose a hazard for falling. The nurse should instruct the client to store extra blankets in a closet or drawer and use handrails when using the stairs.

A. The client is having difficulty reading large print. B. The client coughs while drinking from a straw. C. The client is unable to bear her full weight while walking. D. The client becomes exhausted while brushing her teeth.

Correct Answer is D

Explanation

Choice A: This is incorrect. The client having difficulty reading large print indicates a need for an ophthalmology referral, not an occupational therapy referral. An ophthalmologist can assess and treat vision problems caused by stroke.

Choice B: This is incorrect. The client coughing while drinking from a straw indicates a need for a speech therapy referral, not an occupational therapy referral. A speech therapist can assess and treat swallowing problems caused by stroke.

Choice C: This is incorrect. The client being unable to bear her full weight while walking indicates a need for a physical therapy referral, not an occupational therapy referral. A physical therapist can assess and treat mobility problems caused by stroke.

Choice D: This is correct. The client becoming exhausted while brushing her teeth indicates a need for an occupational therapy referral. An occupational therapist can assess and treat functional problems caused by stroke, such as fatigue, self-care, cognition, and leisure activities.

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A nurse is caring for a client who has dementia and wanders frequently. Which of the following actions should the nurse take?

Nursing Test Bank

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