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: This response is appropriate because it encourages the client to seek professional medical advice, ensuring they receive personalized recommendations based on their health status and needs. It also emphasizes the importance of a physical examination to rule out any contraindications or underlying health issues before starting any contraceptive method.
Choice B reason: Storing the CPM machine on the floor when not in use is not recommended as it can pose a tripping hazard and may not comply with safety standards. The machine should be stored properly according to the manufacturer's instructions to ensure safety and maintain the equipment's integrity.
Choice C reason:While barrier methods are a good option for preventing both pregnancy and sexually transmitted infections (STIs), suggesting a specific method without a full assessment of the client's needs and preferences is not ideal. It is better to involve a healthcare provider in the decision-making process.
Choice D reason: Increasing the range of motion rapidly when the CPM machine is used intermittently is not advised. Adjustments to the range of motion should be made gradually and according to the client's tolerance and the surgeon's orders. Rapid increases can cause pain and may hinder the healing process.
Correct Answer is C
Explanation
Choice A reason: A headache following a grade 1 concussion, while requiring monitoring, does not typically necessitate immediate proximity to the nurses' station. Grade 1 concussions are considered mild and usually do not involve loss of consciousness.
Choice B reason: A client who has experienced brain death and is awaiting organ procurement will not benefit from being close to the nurses' station due to the irreversible nature of brain death. The care for such a client is focused on maintaining organ viability for transplantation.
Choice C reason: A client with a score of 10 on the Glasgow Coma Scale following a motor vehicle crash should be placed closest to the nurses' station. A GCS score of 10 indicates a moderate level of impairment in consciousness and potentially unstable vital signs, requiring close monitoring and rapid nursing intervention.
Choice D reason: A score of 0 on the NIH Stroke Scale indicates no observable neurological deficit. Clients with a transient ischemic attack (TIA) and a score of 0 would require less intensive observation compared to those with higher scores or other acute neurological injuries.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.