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.

Answer and Explanation

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.

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Correct Answer is ["D","E"]

Explanation

A. Place the child in prone position:

Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.

B. Restrain the child:

Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.

C. Place a tongue depressor in the child's mouth:

It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.

D. Clear the area of hard objects:

Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.

E. Loosen restrictive clothing:

Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.

A. Inject the medication deep into the thigh muscle. B. Easy bruising indicates the medication is effective. C. Expect stools to become black and tarry. D. Use a soft bristle toothbrush.

Correct Answer is D

Explanation

A. Inject the medication deep into the thigh muscle.

This statement is incorrect for subcutaneous heparin administration. Heparin is typically administered subcutaneously in the fatty tissue just under the skin, not into the muscle. Intramuscular injection is not appropriate for heparin.

B. Easy bruising indicates the medication is effective.

This statement is inaccurate. Easy bruising is not an indicator of the effectiveness of heparin. In fact, excessive bruising can be a side effect of anticoagulant therapy, indicating a potential issue with bleeding or clotting.

C. Expect stools to become black and tarry.

This statement is more relevant to medications like iron supplements or upper gastrointestinal bleeding. It is not a common side effect of subcutaneous heparin.

D. Use a soft bristle toothbrush.

This statement is correct. It is important for individuals on anticoagulant therapy, such as heparin, to use a soft bristle toothbrush to minimize the risk of bleeding and gum irritation. Hard bristle toothbrushes can cause gum bleeding, especially in individuals with a tendency for bleeding due to anticoagulant use.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Correct Answer is ["D","E"]

Explanation

A nurse is reinforcing teaching with a client who is to start subcutaneous heparin. Which of the following information should the nurse include in the teaching?

Correct Answer is D

Explanation

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