A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

Apply a vest restraint on the client.

Place the client in bed with the two side rails raised.

Place a seat alarm in the client's chair.

Administer lorazepam the client.

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.

Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.

Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.

Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted

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Correct Answer is A

Explanation

Choice A Rationale: The client receiving an influenza vaccine 4 weeks ago is relevant because Guillain-Barre syndrome can sometimes be triggered by infections or vaccinations, including influenza vaccines.

Choice B Rationale: The client's hobby of golfing is not directly related to the described symptoms.

Choice C Rationale: Canning jams and preserves is not directly related to the described symptoms.

Choice D Rationale: A history of diabetes, while important for the client's overall health, may not be directly related to the current manifestations.

A. A Keep window blinds open during the day B. B Have the patient take a mid-morning nap. C. C Provide hourly orientation to time and place. D. D Move the patient to a quiet room in the afternoon.

Correct Answer is A

Explanation

Choice A Rationale: Keeping window blinds open during the day is a non pharmacological approach to help regulate the patient's circadian rhythm and may reduce the severity of sundowning, a common phenomenon in dementia.

Choice B Rationale: Having the patient take a mid-morning nap may disrupt the patient's sleep-wake cycle and worsen sundowning.

Choice C Rationale: Providing hourly orientation to time and place may be overwhelming for the patient and not necessarily effective in addressing sundowning.

Choice D Rationale: Moving the patient to a quiet room in the afternoon may not address the underlying issue of sundowning and may not be practical in a long-term care setting.

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