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 C
Explanation
Choice A Rationale: Unscrewing the pins from the cervical tongs is not the best first action for bathing a client with a spinal cord injury.
Choice B Rationale: Asking the client to sit on the edge of the bed may not be appropriate or safe without proper assistance and equipment.
Choice C Rationale: The best first action is to gather supplies and at least 3 other people. Bathing a client with a spinal cord injury can be complex and may require additional assistance for safety and comfort.
Choice D Rationale: Removing the straps from the halo vest is not the first step in the bathing process and may not be necessary.
Correct Answer is A
Explanation
Choice A Rationale: Being currently pregnant is a risk factor for developing Bell's Palsy.
Choice B Rationale: Thyroid disease is not a direct risk factor or consistent finding in Bell's Palsy.
Choice C Rationale: Having a seizure disorder is not directly related to Bell's Palsy.
Choice D Rationale: Current smoking is not a risk factor associated with Bell's Palsy
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