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
Explanation
Choice A Rationale: Simple puzzles are appropriate activities for a client with severe Alzheimer's because they stimulate cognitive function and provide a sense of accomplishment.
Choice B Rationale: Board games are too complex and frustrating for a client with severe Alzheimer's, as they require memory, strategy, and social interaction.
Choice C Rationale: Dangling ribbons or a mobile are infantile and demeaning activities that do not respect the dignity and autonomy of the client.
Choice D Rationale: Drawing with crayons may be suitable for some clients with Alzheimer's, but it is not specific to the diagnosis and may not appeal to all clients.
Correct Answer is B
Explanation
Choice A Rationale: hyperextension is when the neck is bent backward beyond its normal range of motion. This can happen in a rear-end collision or a fall on the back of the head.
Choice B Rationale: A spinal cord injury occurs when there is damage to the spinal cord or the surrounding structures, such as the vertebrae, ligaments, or discs. The most common cause of spinal cord injury is trauma, which can result from direct impact, penetration, or excessive force on the spine. Diving into shallow water can cause compression of the spine, which means that the vertebrae are pushed together and squeeze the spinal cord. This can damage the nerve fibers and disrupt the communicationbetween the brain and the body. Compression injuries can affect any part of the spine, but are more common in the cervical and thoracic regions.
Choice C Rationale: flexion-rotation is when the neck is bent and twisted at the same time. This can happen in a sports injury or a violent assault.
Choice D Rationale: This is when the neck is bent forward beyond its normal range of motion. This can cause the posterior part of the vertebral column to compress and fracture, while the anterior part of the spinal cord is stretched and injured. This can happen in a head-on collision or a fall on the face. A flexion-rotation is when the neck is bent and twisted at the same time.
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