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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
Choice A Rationale: Understanding the expected physiological changes of Alzheimer's disease can help the caregiver better cope with the client's behaviors and needs.
Choice B Rationale: Teaching actions to reduce stress is important for both the caregiver and the client, as stress can exacerbate behavioral symptoms in Alzheimer's disease.
Choice C Rationale: Referring to available community resources can provide valuable support and assistance to both the caregiver and the client.
Choice D Rationale: Identifying a social support system is essential for the caregiver to have emotional and practical support while caring for a client with Alzheimer's disease.
Choice E Rationale: While medication administration is important, it may not be the primary focus of coping strategies for the caregiver.
Correct Answer is D
Explanation
Choice A Rationale: Dementia is not characterized by a sudden onset of confusion. It is a gradual and progressive condition.
Choice B Rationale: Dementia can be triggered or worsened by factors like infections, but it is not primarily characterized by a high fever or dehydration.
Choice C Rationale: An altered level of consciousness is not typically associated with dementia but may occur in acute delirium.
Choice D Rationale: The nurse should explain to the family that dementia is a chronic condition that affects the brain and causes cognitive impairment, memory loss, andbehavioral changes. The nurse should also inform the family that dementia is not caused by a single factor, but by a combination of genetic, environmental, and lifestyle factors. The nurse should emphasize that dementia is not a normal part of aging, and that it has different stages and types.
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