A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
Encourage frequent visits from friends.
Keep the over-the-bed light on.
Apply restraints to the upper extremities.
Play serene, soothing music.
The Correct Answer is D
A. Encourage frequent visits from friends: While social interaction can be beneficial, it’s important to consider the individual’s needs and preferences. Overstimulation from too many visitors can cause anxiety or confusion, which can worsen cognitive symptoms.
B. Keep the over-the-bed light on: This may be helpful in preventing falls or confusion at night. However, it’s essential to avoid excessive lighting as it can disrupt the circadian rhythm, potentially leading to sleep disturbances. A dim nightlight is more appropriate.
C. Apply restraints to the upper extremities: Restraints should not be used as a first-line approach. They can increase confusion, anxiety, and the risk of injury. Non-restrictive interventions, such as proper positioning and a calm environment, should be prioritized.
D. Play serene, soothing music: Soothing music can be a helpful intervention to reduce anxiety, agitation, and confusion in clients with dementia. Music has been shown to have a calming effect, which can help the client feel more relaxed and at ease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E","F"]
Explanation
Rationale for Correct Answers
- How to check blood glucose at home: The client has hyperglycemia and may have undiagnosed diabetes. Teaching self-monitoring of blood glucose is essential for ongoing glycemic control, treatment adjustments, and early detection of dangerous fluctuations.
- Manifestations of hyperglycemia and hypoglycaemia: The client is already showing signs of hyperglycemia (polyuria, weight loss, fatigue). Understanding the symptoms of both high and low blood sugar helps prevent complications and allows timely self-intervention.
- Perform 100 min of physical activity per week: Moderate physical activity helps improve insulin sensitivity and blood glucose regulation. While 150 min/week is ideal, 100 min is a beneficial starting point for clients new to exercise or with complications like foot ulcers.
- Weight loss tips: The client has a BMI of 27, which falls into the overweight category. Weight loss is often beneficial for improving blood glucose control in individuals with type 2 diabetes and reducing overall health risks.
Rationale for Incorrect Answers
- Instructions on how to take metoprolol: There is no indication in the data that the client has hypertension, arrhythmia, or another condition that warrants beta-blocker therapy. Teaching this would be irrelevant unless metoprolol is newly prescribed.
- Check feet weekly on the same day each week: Clients with diabetes or suspected diabetes should be taught to inspect their feet daily, not weekly. Delayed detection of wounds or infection can lead to severe complications, including amputation.
Correct Answer is D
Explanation
A. Blood pressure 140/90 mm Hg: This blood pressure reading is elevated but does not specifically suggest a pulmonary embolism (PE). It could be due to other factors such as anxiety or pain, and it is not a primary indicator of PE.
B. Respiratory rate 12/min: A respiratory rate of 12/min is within the normal range (12-20 breaths per minute). A PE typically causes an increased respiratory rate as the body attempts to compensate for impaired oxygenation: normal respiratory rate does not suggest PE.
C. Temperature 40° C (104° F): A fever of 40° C (104° F) is significantly elevated and suggests an infection or inflammation. While a PE can cause mild fever, a temperature of 40° C is more commonly associated with infection rather than a pulmonary embolism.
D. Heart rate 120/min: A heart rate of 120/min is indicative of tachycardia, which is a common response to a pulmonary embolism. The body tries to compensate for reduced oxygenation by increasing heart rate. Tachycardia, along with other symptoms such as shortness of breath and chest pain, is a key indicator of PE.
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