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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: This is incorrect because dimming the lights in the client's room is not a helpful action for providing discharge teaching for a client who has hearing loss. Dimming the lights can reduce the visibility and clarity of the nurse's facial expressions, gestures, and lip movements, which can aid in communication.
Choice B Reason: This is incorrect because increasing the rate of speech when talking with the client is not an effective action for providing discharge teaching for a client who has hearing loss. Increasing the rate of speech can make it harder for the client to follow and understand what the nurse is saying.
Choice C Reason: This is incorrect because answering client's questions using medical terminology is not an appropriate action for providing discharge teaching for a client who has hearing loss. Medical terminology can be confusing and unfamiliar to the client, which can impair comprehension and learning.
Choice D Reason: This is the correct choice because facing the client while talking is an important action for providing discharge teaching for a client who has hearing loss. Facing the client can enhance eye contact, attention, and rapport. It can also allow the client to see the nurse's facial expressions, gestures, and lip movements, which can facilitate communication.
Correct Answer is B
Explanation
Choice A Reason: Depth perception is the ability to judge the distance and position of objects in three-dimensional space. Depth perception is assessed by asking the client to touch the tip of a pen or pencil held by the nurse, or by using a stereopsis test.
Choice B Reason: Peripheral vision is the ability to see objects and movements outside the direct line of vision. Peripheral vision is assessed by asking the client to shake the hand of the nurse, who stands at an angle to the client's side, or by using a confrontation test.
Choice C Reason: Color deficit is the inability to distinguish certain colors or shades of colors. Color deficit is assessed by asking the client to identify numbers or shapes on a color plate test, such as the Ishihara test.
Choice D Reason: Double vision is the perception of two images of a single object. Double vision is assessed by asking the client to cover one eye and look at an object, then switch eyes and compare the images, or by using a cover-uncover test.
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