A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?
Move the client to a double room.
Use a bed alarm.
Encourage participation in activities that provide excessive stimulation.
Use chemical restraints at bedtime.
The Correct Answer is B
Choice A reason: Moving the client to a double room may not be effective in preventing wandering and could potentially lead to confusion or agitation if the client is not comfortable with the roommate or the new environment.
Choice B reason: Using a bed alarm is a non-invasive way to alert staff if the client attempts to leave the bed. This can help prevent wandering and ensure the safety of the client without restricting their movement unnecessarily.
Choice C reason: Encouraging participation in activities that provide excessive stimulation is not recommended for clients with dementia, as it can lead to increased confusion, agitation, and potentially exacerbate wandering behaviors.
Choice D reason: The use of chemical restraints, such as sedative medications, should be a last resort and only used when necessary to ensure the safety of the client or others. It is important to use the least restrictive measures first and to always consider the ethical implications of using chemical restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Glycosylated hemoglobin, also known as hemoglobin A1C, reflects the average blood glucose levels over the past two to three months. It is a crucial indicator of long-term glycemic control in individuals with diabetes. The American Diabetes Association recommends that the A1C level be checked at least two times a year in patients who are meeting treatment goals and have stable glycemic control. An A1C level below 7% is generally considered good control, and achieving this target can reduce microvascular complications of diabetes.
Choice B reason: Postprandial blood glucose levels indicate the amount of glucose in the blood after a meal. While it's an important measure, it reflects only the immediate response to food intake and does not provide information about long-term glycemic control.
Choice C reason: Fasting blood glucose levels measure the amount of glucose in the blood after an overnight fast. This test is used to detect diabetes or prediabetes but is less effective than the A1C test for monitoring long-term glycemic control.
Choice D reason: The oral glucose tolerance test (OGTT) measures blood glucose levels before and two hours after consuming a glucose-rich drink. This test is primarily used for diagnosing diabetes and gestational diabetes, not for long-term monitoring.
Correct Answer is D
Explanation
Choice A reason: Applying antibiotic ointment to the lesions is not recommended for the treatment of genital herpes, which is caused by a virus, not bacteria. Antiviral medications are the appropriate treatment for managing herpes outbreaks.
Choice B reason: Natural skin condoms are not effective in preventing the transmission of genital herpes because the virus can pass through the natural membrane. The use of latex or polyurethane condoms is recommended as they are more effective in reducing the risk of transmission.
Choice C reason: Expecting lesions to resolve in 6 weeks may not be accurate as the duration of a herpes outbreak can vary. Most herpes lesions tend to resolve within 2 to 4 weeks. However, the virus remains in the body and can cause recurrent outbreaks.
Choice D reason: The duration of medication for genital herpes depends on whether the treatment is for an initial outbreak, chronic suppression, or episodic therapy. For an initial outbreak, antiviral medication is typically taken for 7 to 10 days. For chronic suppression, medication might be taken daily for an extended period to prevent or reduce the frequency of outbreaks.
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