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 C
Explanation
Choice A Reason: Inserting a nasal swab to observe the fluid is contraindicated, as it can introduce infection or increase intracranial pressure. The fluid can be tested for glucose or halo sign to confirm cerebrospinal fluid (CSF) leakage.
Choice B Reason: Suctioning the nose gently with a bulb syringe is also contraindicated, as it can create negative pressure and increase CSF leakage or cause meningitis.
Choice C Reason: This is the correct answer because allowing the drainage to drip onto a sterile gauze pad can prevent contamination and facilitate observation of the amount and characteristics of the fluid.
Choice D Reason: Inserting sterile packing into the nares is not recommended, as it can obstruct the drainage and increase intracranial pressure or infection risk.
Correct Answer is D
Explanation
Choice A Reason: This choice is incorrect. Losing bladder control is not a feature of complex partial seizures, but rather of generalized tonic-clonic seizures. Complex partial seizures are a type of focal seizures that affect a specific area of the brain and cause impaired awareness and automatisms. Automatisms are repetitive and involuntary movements or behaviors that occur during a seizure.
Choice B Reason: This choice is incorrect. Having fixed and dilated eyes is not a feature of complex partial seizures, but rather of brain death or severe brain injury. Complex partial seizures do not affect the pupils or eye movements, but rather the level of consciousness and motor activity.
Choice C Reason: This choice is incorrect. Making involuntary groaning sounds is not a feature of complex partial seizures, but rather of simple partial seizures. Simple partial seizures are a type of focal seizures that affect a specific area of the brain and do not impair awareness or cause automatisms. They can cause sensory, motor, or psychic symptoms, such as auditory or visual hallucinations, tingling sensations, or emotional changes.
Choice D Reason: This is the correct choice. Having involuntary facial movements, such as lip-smacking, is a feature of complex partial seizures. Complex partial seizures often originate from the temporal lobe of the brain, which is involved in memory, language, and emotion. They can cause automatisms that affect the mouth, face, or hands, such as chewing, swallowing, picking, or fidgeting.
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