A nurse is caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?
Keep the client's personal items within reach.
Tell the family that someone should plan to stay with the client.
Place the client in a quiet room at the end of the hallway.
Provide bright lighting in the client's room at night.
The Correct Answer is A
A. Keep the client's personal items within reach. Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.
Incorrect options:
B. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.
C. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.
D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A 15-year-old client who has acne:
Acne alone is not a contraindication to oral contraceptives. In fact, oral contraceptives can sometimes be prescribed to help manage acne.
B. A client who has a menstrual cycle every 14 days:
Having a menstrual cycle every 14 days may indicate an irregular cycle, but it's not a direct contraindication to oral contraceptives. However, the cause of the frequent cycles might need evaluation before starting oral contraceptives.
C. A client who has a blood pressure of 140/90 mm Hg:
Elevated blood pressure (140/90 mm Hg or higher) is a contraindication to oral contraceptives. It increases the risk of complications such as stroke, heart attack, or other cardiovascular issues.
D. A client who has a hematocrit of 39%:
A hematocrit level of 39% is within the normal range and is not a contraindication to oral contraceptives.
Correct Answer is ["A","B","C","E"]
Explanation
A. Placing the bedside table within the client's reach helps to minimize the need for the older adult to reach or stretch, reducing the risk of falls.
B. Keeping the bed at a comfortable working height makes it easier for the older adult to get in and out of bed safely.
C. Keeping a night light on in the client's room and bathroom helps improve visibility during the night, reducing the risk of tripping or falling.
D. Administering a sedative at bedtime is generally not recommended as a preventive measure for falls. Sedatives can increase the risk of drowsiness and impaired balance, contributing to falls.
E. Locking the wheels on beds and wheelchairs during transfers helps ensure stability and prevents the equipment from moving unexpectedly, reducing the risk of falls during transfers.
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