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 C
Explanation
Choice A reason: Digoxin is primarily used to treat atrial fibrillation and heart failure. It is not the first-line medication for sinus bradycardia with ST-segment elevation, as it can further slow down the heart rate.
Choice B reason: Sotalol is a beta-blocker and an antiarrhythmic medication that can be used to treat ventricular arrhythmias and maintain sinus rhythm in atrial fibrillation. However, it is not indicated for sinus bradycardia and could exacerbate the condition.
Choice C reason: Atropine is the medication of choice for symptomatic sinus bradycardia. It works by blocking the action of the vagus nerve on the heart, leading to an increased heart rate. Atropine can quickly reverse the symptoms of bradycardia, such as dizziness and shortness of breath.
Choice D reason: Lidocaine is an antiarrhythmic medication used to treat ventricular arrhythmias. While it can be used in acute settings, it is not the first choice for sinus bradycardia with ST-segment elevation.
Correct Answer is A
Explanation
Choice A reason: Asking if the client feels like they have food stuck at the base of their throat is a pertinent question for assessing swallowing in a client with oral achalasia. Achalasia is characterized by difficulty in swallowing due to the inability of the lower esophageal sphincter to relax, leading to a sensation of food being stuck.
Choice B reason: While burning sensations in the throat can be associated with gastroesophageal reflux disease (GERD), they are not specific to achalasia. However, some clients with achalasia may experience similar symptoms due to food stasis and fermentation in the esophagus.
Choice C reason: Feelings of fullness in the neck are not a typical symptom of achalasia. Achalasia primarily affects the esophagus and does not usually cause a sensation of fullness in the neck.
Choice D reason: Pain while swallowing, or odynophagia, can occur in achalasia but is more commonly associated with conditions that cause inflammation or irritation of the esophagus, such as infections or ingestion of irritants.
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