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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Telling a family to limit discussing past events with the client may not be culturally sensitive. Each culture has its own views on reminiscing and sharing memories, especially during end-of-life care. Some cultures value the sharing of stories and memories as a way to honor the individual's life.
Choice B reason: Saying "We will respect what is important to you" is a statement that acknowledges and incorporates the client's and family's cultural beliefs. It shows a willingness to understand and prioritize their values, customs, and preferences in the care plan. This approach is aligned with culturally competent care, which is crucial in hospice settings.
Choice C reason: Offering to arrange all burial services may overstep boundaries, as burial practices are deeply rooted in cultural and religious beliefs. It is important for healthcare providers to discuss and understand the family's wishes and provide support in accordance with their specific cultural practices.
Choice D reason: Advising that grieving should not be done in front of the client may not align with the family's cultural beliefs about expressing emotions and grief. Different cultures have varied expressions of grief, and it is essential to respect these practices. Some cultures view the open expression of grief as an important part of the mourning process.

Correct Answer is D
Explanation
Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. It is a medical emergency that requires treatment in a hospital, but it is not contagious.
Choice B reason: An older adult client admitted with aspiration pneumonia would not typically require a private room solely based on this condition. Aspiration pneumonia is caused by inhaling food, stomach acid, or saliva into the lungs. It can lead to a bacterial infection, which may or may not be contagious depending on the causative organism.
Choice C reason: A client with a compound fracture of the right femur would not require a private room based on the diagnosis alone. A compound fracture, also known as an open fracture, is a fracture in which there is an open wound or break in the skin near the site of the broken bone. While it requires immediate medical attention to prevent infection, it is not a condition that necessitates isolation.
Choice D reason: A client who reports having fever, night sweats, and cough for 2 days may require a private room due to the possibility of an infectious disease that could be transmitted to others, such as tuberculosis (TB). These symptoms are concerning for TB, which is an airborne infectious disease and would require airborne precautions, including a private room with negative pressure ventilation.
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