A nurse is preparing a staff training on fall prevention for clients who have moderate dementia. Which of the following strategies should the nurse include?

Delegate scheduled checks to assistive personnel.

Ensure all the side rails are up when the client is in bed.

Collaborate with a provider to request PRN standard prescriptions for sedatives.

Keep televisions on around the unit for distraction.

Answer and Explanation

The Correct Answer is A

A. Delegate scheduled checks to assistive personnel: Regular, scheduled checks help monitor clients with moderate dementia for signs of restlessness, wandering, or unsafe behaviors that could lead to falls. Delegating this task ensures consistent supervision and enhances safety.

B. Ensure all the side rails are up when the client is in bed: Raising all side rails can actually increase the risk of injury, as clients with dementia may attempt to climb over them, leading to falls or entrapment. Side rails should be used judiciously and according to safety guidelines.

C. Collaborate with a provider to request PRN standard prescriptions for sedatives: Routine use of sedatives can increase confusion, dizziness, and fall risk in clients with dementia. Nonpharmacologic fall prevention strategies are preferred whenever possible.

D. Keep televisions on around the unit for distraction: Continuous background noise or television can be overstimulating and may increase agitation in clients with dementia, potentially increasing the risk of falls rather than preventing them.

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Correct Answer is C

Explanation

A. The client's activity level: Physical activity is a modifiable risk factor because the client can increase exercise to reduce cardiovascular risk. Lifestyle changes in activity level can significantly impact heart health and recovery after a myocardial infarction.

B. The client's stress level: Stress is a modifiable risk factor as clients can employ stress-reduction techniques, counseling, or lifestyle modifications to lower cardiovascular risk. Managing stress can improve both short-term and long-term cardiac outcomes.

C. The client's race: Race is a nonmodifiable risk factor because it is inherent and cannot be changed. Certain racial and ethnic groups have a higher prevalence of cardiovascular disease due to genetic, socioeconomic, and health access factors.

D. The client's diet: Diet is a modifiable risk factor since clients can adjust their nutritional intake to reduce cholesterol, blood pressure, and overall cardiovascular risk. Nutritional counseling is often part of post-MI care to improve outcomes.

A. The client started working in a parking garage 3 months ago. B. The client is doing 30 min of moderate exercise daily. C. The client is drinking 2.5 L of water per day. D. The client last visited the dentist 4 months ago.

Correct Answer is A

Explanation

A. The client started working in a parking garage 3 months ago: Working in a parking garage can increase exposure to carbon monoxide and other exhaust fumes, which can be harmful to both the pregnant client and the fetus. Prolonged inhalation of these toxins may reduce oxygen delivery and contribute to complications, making this finding a priority for further evaluation.

B. The client is doing 30 min of moderate exercise daily: Moderate exercise is recommended during pregnancy as it improves circulation, reduces stress, and supports healthy weight gain. This behavior is considered safe and beneficial unless otherwise contraindicated by the provider.

C. The client is drinking 2.5 L of water per day: Adequate hydration is essential during pregnancy to support amniotic fluid levels, circulation, and kidney function. A daily intake of 2.5 liters is appropriate and aligns with recommended guidelines for pregnant clients.

D. The client last visited the dentist 4 months ago: Routine dental care is important during pregnancy due to increased risk of gingivitis, but a dental visit 4 months ago does not indicate an unsafe behavior. Continuing regular appointments every 6 months is generally sufficient unless specific concerns arise.

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