A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls. Which of the following actions should the nurse take?
Apply a motion sensor mat to the client's bed.
Move the overbed table away from the bed.
Raise all four side rails while the client is in bed.
Leave the television on in the client's room.
The Correct Answer is A
The correct answer is choice A, apply a motion sensor mat to the client's bed. This is an effective intervention to monitor the client's movements and prevent falls. The mat is placed under the bed sheet and will sound an alarm if the client tries to get out of bed.
- Moving the overbed table away from the bed is not the correct answer because it does not prevent falls.
- Raising all four side rails while the client is in bed is not the correct answer because it can cause the client to feel trapped and can lead to injuries if they try to climb over the rails.
- Leaving the television on in the client's room is not the correct answer because it can be distracting and interfere with the client's sleep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
"The lesions may reoccur in times of stress." This statement indicates that the client understands that the virus can reactivate and cause new outbreaks during times of stress.
Choice A is not correct because thevirus can spread to other areas through skin-to-skin contact.
Choice C is not correct because the virus can still be contagious even when no lesions are present.
Choice D is not correct because having unprotected sex can still transmit the virus even while taking acyclovir.
Correct Answer is B
Explanation
A platelet count of 60,000/mm² is below the expected reference range, and the nurse should report this value to the provider. Ammonia, aspartate aminotransferase, and bilirubin values are within expected reference ranges and do not require further reporting.
Other choices are not correct because:
A. Ammonia 55 mcg/dL: Is within the expected reference range and does not require further reporting.
C. Aspartate aminotransferase 34 units/L: Is within the expected reference range and does not require further reporting.
D. Bilirubin 1.0 mg/dL: Is within the expected reference range and does not require further reporting.
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