A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?.

Lower the window shade in the client's room.

Obtain a PRN prescription for a vest restraint.

Place the client in a room close to the nurses' station.

Request a consult with recreational therapy.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.

Choice B rationale:

Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.

Choice C rationale:

Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.

Choice D rationale:

While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.

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Correct Answer is B

Explanation

Choice A rationale:

Reaction formation is a defense mechanism where a person behaves in a way opposite to their true feelings.

Choice B rationale:

Somatization is the process of experiencing mental or emotional distress as physical symptoms.

Choice C rationale:

Intellectualization is a defense mechanism where a person uses reasoning to block out emotional stress.

Choice D rationale:

Sublimation is a defense mechanism where a person transforms unacceptable impulses into socially acceptable behaviors.

A. Encourage the client to visit with the sibling. B. Tell the sibling the client does not want visitors. C. Arrange for the sibling to visit the client in the dayroom. D. Refer the sibling to the client's provider.

Correct Answer is B

Explanation

Choice A rationale:

It’s not appropriate to pressure the client into seeing visitors.

Choice B rationale:

It’s important to respect the client’s wishes and communicate them to the sibling.

Choice C rationale:

This could potentially cause distress for the client.

Choice D rationale:

While it might be helpful to involve the provider, the immediate issue can be addressed by the nurse.

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A nurse is caring for a client who has dementia and is experiencing an increased number of falls. Which of the following actions should the nurse take?.

Nursing Test Bank

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A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?.