It is night time and a client who suffers from dementia is agitated and is having difficulty staying in his bed. Which of the following actions should the nurse take first?

Turn off the lights and TV and close the door for privacy

Use one wrist restraint to keep the client safe

Ask the physician for a sedative

Identify if there is a cause for the agitation

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because turning off the lights and TV and closing the door may increase the client's anxiety and confusion. The nurse should provide adequate lighting and familiar objects to help orient the client.

Choice B Reason: This is incorrect because using restraints may increase the risk of injury, infection, and psychological distress for the client. The nurse should use restraints only as a last resort and with a physician's order.

Choice C Reason: This is incorrect because asking for a sedative may not address the underlying cause of the agitation. The nurse should use non-pharmacological interventions first, such as calming music, massage, or aromatherapy.

Choice D Reason: This is correct because identifying the cause of the agitation may help resolve it. The nurse should assess for possible triggers, such as pain, hunger, thirst, infection, or environmental factors.

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Correct Answer is D

Explanation

Choice A Reason: This is incorrect because phototherapy is not a recommended therapy for contact dermatitis. Phototherapy involves exposing the skin to artificial light sources that emit specific wavelengths of light that can have anti-inflammatory or immunomodulatory effects. Phototherapy can be used for some skin conditions, such as psoriasis or eczema, but not for contact dermatitis.

Choice B Reason: This is incorrect because antibiotics are not a recommended therapy for contact dermatitis. Antibiotics are drugs that kill or inhibit bacteria that cause infections. Contact dermatitis is not an infection, but an allergic or irritant reaction to a substance that comes in contact with the skin. Antibiotics have no effect on contact dermatitis and may cause adverse effects or resistance.

Choice C Reason: This is incorrect because UV light is not a recommended therapy for contact dermatitis. UV light refers to ultraviolet radiation from sunlight or artificial sources that can damage DNA and cause skin cancer or aging. UV light can also worsen contact dermatitis by increasing inflammation and sensitivity to allergens or irritants.

Choice D Reason: This is correct because avoidance is the best therapy for contact dermatitis. Avoidance means identifying and avoiding the substance that causes the skin reaction. This can prevent further exposure and allow the skin to heal. The nurse can help the client by providing education on how to read labels, use protective clothing or gloves, or substitute safer products.

A. Resume a functional role in society B. Pain management C. Provide continued full support to the client D. Prevent infection

Correct Answer is A

Explanation

Choice A reason: This is correct because resuming a functional role in society is the ultimate goal for a client in the rehabilitative phase of a burn injury. The rehabilitative phase begins when wound healing is complete and lasts until physical and psychosocial recovery is achieved. The nurse should help the client regain independence, self-esteem, and quality of life by providing education, counseling, referrals, and resources.

Choice B reason: This is incorrect because pain management is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Pain management is important throughout all phases of burn care, but especially during wound healing and scar formation, which can cause itching, tightness, or hypersensitivity. The nurse should assess the client's pain level and administer analgesics, antipruritics, or moisturizers as ordered.

Choice C reason: This is incorrect because providing continued full support to the client is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Providing continued full support to the client can help them cope with physical and emotional challenges, such as scarring, disfigurement, disability, or depression. The nurse should provide emotional support, active listening, positive feedback, and encouragement to the client.

Choice D reason: This is incorrect because preventing infection is not a goal, but an intervention for a client in the rehabilitative phase of a burn injury. Preventing infection is crucial during wound healing and grafting, which can be compromised by bacterial colonization or contamination. The nurse should monitor the client's vital signs, wound appearance, and laboratory results, and administer antibiotics or antiseptics as ordered.

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It is night time and a client who suffers from dementia is agitated and is having difficulty staying in his bed. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with contact dermatitis is receiving education from the nurse. Which of the following therapies will the nurse recommend to the client?

Correct Answer is D

Explanation

When providing information to a client in the rehabilitative phase of a burn injury, which of the following will the nurse identify as the goal?

Correct Answer is A

Explanation

A nurse reviewing a client's chart reads that the client was observed having a complex partial seizure with automatisms of the face. What does the nurse understand this to mean?

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A nurse is teaching a class about physiological changes to hearing in older adult clients. Which of the following should the nurse include?

The physician suspects a client has a dermatological infection. Which of the following diagnostics will be ordered to observe color changes to the skin using an ultraviolet light source?

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