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 A

Explanation

A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.

B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.

C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.

D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.

A. Provide support by holding the client's arm. B. Maintain a narrow base of support. C. Lower the client to the floor. D. Lean the client toward the wall.

Correct Answer is C

Explanation

A. Provide support by holding the client's arm:

While providing support is essential, holding the client's arm may not prevent a fall. It's better to focus on a controlled descent to the floor.

B. Maintain a narrow base of support:

Maintaining a narrow base of support is not advisable when a client is falling. A wider base of support provides more stability.

C. Lower the client to the floor:

This is the correct action. When a client begins to fall, the nurse should lower them to the floor in a controlled manner to minimize the risk of injury.

D. Lean the client toward the wall:

Leaning the client toward the wall may not provide sufficient support during a fall. The goal is to lower the client to the floor in a way that minimizes the risk of injury.

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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?

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Naxlex Comprehensive Predictor Exams

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