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 ["15"]
Explanation
To calculate the dose of amantadine for a client with parkinsonism, the nurse needs to use the formula: Dose (mL) = Ordered dose (mg) / Available dose (mg/mL) x Available volume (mL).
In this case, the ordered dose is 150 mg, the available dose is 50 mg/5 mL, and the available volume is 5 mL.
Plugging these values into the formula, we get: Dose (mL) = 150 mg / (50 mg/5 mL) x 5 mL.
Simplifying, we get: Dose (mL) = 15 mL.
Therefore, the nurse should administer 15 mL of amantadine oral solution to the client.
Correct Answer is A
Explanation
A. Obtain the client's vital signs: The nurse's priority is to assess the client for any injuries or complications that may have occurred during the fall. Obtaining vital signsprovides critical information about the client's immediate health status, such as the presence of hypotension, tachycardia, or other abnormalities that might indicate injury or a medical issue that caused the fall.
B. Inform the client's family member: While it may be necessary to inform the family of the incident, this is not the nurse's first priority. Ensuring the client’s safety and assessing their condition takes precedence.
C. Notify the client's provider: The provider needs to be informed of the fall, especially if there are injuries or changes in the client’s condition. However, this action should occur after the nurse has assessed the client and gathered pertinent information.
D. Assist the client back into bed: The nurse should not move the client until an assessment has been completed. Moving the client without first assessing their condition could potentially worsen any undiagnosed injuries, such as fractures or spinal injuries.
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