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 A

Explanation

Choice A reason: This is correct because the lesion on the child's head is most likely a hemangioma, which is a benign tumor of blood vessels that appears as a red or purple mark on the skin. Hemangiomas are common in newborns and usually grow during the first year of life, then shrink and fade over several years. The nurse should reassure the client that hemangiomas are harmless and do not require treatment unless they interfere with vision, breathing, or feeding.
Choice B reason: This is incorrect because the lesion on the child's head will not spread, but rather grow and shrink within a limited area. The nurse should not alarm the client by suggesting that the lesion will spread to other parts of the body or become malignant. The nurse should explain that hemangiomas are not contagious or infectious and do not affect the child's overall health or development.
Choice C reason: This is incorrect because the lesion on the child's head is not caused by scarring from the birth process, but rather by abnormal growth of blood vessels in the skin. The nurse should not confuse or misinform the client about the cause of the lesion. The nurse should explain that hemangiomas are not related to trauma, infection, or genetics, but rather to unknown factors that influence blood vessel formation during fetal development.
Choice D reason: This is incorrect because the lesion on the child's head is not a precancerous lesion and does not need a referral to a dermatologist. The nurse should not scare or mislead the client by suggesting that the lesion is a sign of cancer or requires further evaluation or treatment. The nurse should explain that hemangiomas are benign and usually resolve on their own without any complications or sequelae.

A. Nystagmus B. Decorticate positioning C. Lack of any response D. Decerebrate positioning

Correct Answer is D

Explanation

Choice A Reason: This is incorrect because nystagmus is not a response to stimuli, but a condition that causes involuntary eye movements. Nystagmus can be caused by various factors, such as inner ear disorders, brain lesions, or drug toxicity, but not necessarily by cervical spine injury.

Choice B Reason: This is incorrect because decorticate positioning is a response to stimuli that indicates damage to the cerebral cortex or the corticospinal tract. Decorticate positioning is characterized by flexion of the arms and extension of the legs. It does not indicate cervical spine injury, which affects the spinal cord below the brainstem.

Choice C Reason: This is incorrect because lack of any response to stimuli can indicate various levels of brain damage or coma, but not specifically cervical spine injury. Lack of any response can also be influenced by other factors, such as sedation, hypothermia, or shock.

Choice D Reason: This is correct because decerebrate positioning is a response to stimuli that indicates damage to the brainstem or the upper cervical spine. Decerebrate positioning is characterized by extension and outward rotation of the arms and legs. It indicates a severe and life-threatening injury that can impair vital functions, such as breathing and blood pressure.

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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 with a newborn asks about the lesion on her child's head. After assessing the skin, which response will the nurse offer to the client?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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