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 A
Explanation
Choice A reason: This is the correct answer because the Amsler grid test is performed to diagnose macular degeneration. The Amsler grid is a pattern of straight lines with a dot in the center. The client is asked to look at the dot and report any distortions or missing areas in the grid. This can indicate damage to the macula, which is the central part of the retina that provides sharp vision.
Choice B reason: This is incorrect because the Snellen chart test is not performed to diagnose macular degeneration. The Snellen chart is a chart of letters of different sizes that are read from a distance. The client is asked to read the smallest line they can see clearly. This can indicate visual acuity or sharpness of vision, but not macular degeneration.
Choice C reason: This is incorrect because the intraocular pressure test is not performed to diagnose macular degeneration. The intraocular pressure test measures the pressure inside the eye using a device called a tonometer. The client may feel a puff of air or a gentle touch on their eye. This can indicate glaucoma, which is a condition where increased pressure damages the optic nerve, but not macular degeneration.
Choice D reason: This is incorrect because the refraction test is not performed to diagnose macular degeneration. The refraction test measures how well the eye bends light rays using a device called a phoropter. The client looks through different lenses and reports which ones make their vision clearer. This can indicate refractive errors such as nearsightedness, farsightedness, or astigmatism, but not macular degeneration.
Correct Answer is ["D","E"]
Explanation
Choice A Reason: This choice is incorrect. Placing the client into a supine position is not an action that the nurse should take, as it can compromise the airway and increase the risk of aspiration. The nurse should position the client on their side with their head tilted slightly forward to allow saliva and secretions to drain out of their mouth.
Choice B Reason: This choice is incorrect. Applying restraints is not an action that the nurse should take, as it can cause injury and increase agitation. The nurse should protect the client from harm by removing any objects or furniture that may cause harm and padding any hard surfaces with blankets or pillows.
Choice C Reason: This choice is incorrect. Inserting a bite stick into the client's mouth is not an action that the nurse should take, as it can cause injury and obstruction. The nurse should never force anything into the client's mouth during a seizure, as it can damage their teeth, gums, tongue, or jaw.
Choice D Reason: This is a correct choice. Loosening restrictive clothing is an action that the nurse should take, as it can improve breathing and circulation. The nurse should unbutton any tight collars, belts, or ties that may constrict the chest or neck.
Choice E Reason: This is a correct choice. Placing a pillow under the client's head is an action that the nurse should take, as it can prevent injury and provide comfort. The nurse should support the client's head with a soft pillow or cushion to prevent hitting it against any hard surfaces.
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