A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
Place the client's bed at the lowest height.
Request a prescription for a nightly sedative.
Assist the client with toileting at least once every 4 hours.
Turn off all lights in the client's room at night.
The Correct Answer is A
Choice A reason: Placing the client's bed at the lowest height is a safety intervention that minimizes the risk of injury from falls, which is particularly important for clients with dementia who may have impaired mobility or judgment. Lowering the bed height can reduce the severity of an injury if a fall does occur. Additionally, it can facilitate easier access for the client to get in and out of bed with less assistance.
Choice B reason: Requesting a prescription for a nightly sedative is not typically recommended as a first-line intervention for clients with dementia. Sedatives can increase the risk of confusion, falls, and can worsen cognitive impairment in the elderly. Non-pharmacological approaches are preferred for managing sleep disturbances in dementia patients.
Choice C reason: Assisting the client with toileting at least once every 4 hours is an important intervention to maintain hygiene and comfort, as well as to prevent urinary tract infections and skin breakdown. However, the frequency of toileting assistance should be individualized based on the client's needs and level of incontinence.
Choice D reason: Turning off all lights in the client's room at night is not advisable as some clients with dementia may experience increased confusion or agitation in complete darkness. A nightlight or low-level lighting can provide a safer environment and help to orient the client during nighttime hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Drawing the regular insulin into the syringe first is correct. When mixing two types of insulin, the clear (regular) insulin should be drawn up before the cloudy (NPH) insulin to prevent contamination.
Choice B reason: Storing prefilled syringes with the needle pointed upward can cause air bubbles to move into the insulin, which can alter the dose when injected. The needle should be pointed downward.
Choice C reason: Shaking the NPH vial vigorously is not recommended as it can create air bubbles and affect the insulin dose. Instead, the vial should be gently rolled between the hands to mix the insulin.
Choice D reason: Inserting the needle at a 15-degree angle is incorrect for subcutaneous injections. A 90-degree angle is typically used unless the patient is very thin, in which case a 45-degree angle may be used.
Correct Answer is B
Explanation
Choice A reason: The client's effort to protect their skin due to increased fragility is a normal part of the aging process. As the skin ages, it becomes thinner and less elastic, making it more susceptible to injuries. The client's proactive approach to skin care is appropriate and does not indicate a need for follow-up.
Choice B reason: The statement "I guess feeling down is just part of aging" suggests a possible misconception about mental health and aging. While it's true that older adults may face various challenges that can affect their mood, persistent feelings of sadness or depression are not a normal part of aging and should be addressed. Mental health is as important as physical health, and feeling down can be a sign of depression, which is treatable at any age.
Choice C reason: Concerns about changes in appearance, such as hair thinning, are common as people age. The client's plan to visit a wig shop indicates they are taking steps to manage these changes and maintain their self-esteem. This does not necessarily indicate a need for follow-up unless the hair loss is sudden or accompanied by other symptoms that could suggest an underlying health issue.
Choice D reason: Missing an appointment but taking the initiative to reschedule shows that the client is actively managing their health care. Regular eye exams are important for older adults as they can help detect vision changes and conditions like glaucoma or cataracts early on. This behavior is responsible and does not indicate a need for follow-up.
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