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 D

Explanation

Choice A rationale:

Absence of seizures is not an expected outcome of fluoxetine therapy. Fluoxetine is an antidepressant, not an anticonvulsant.

Choice B rationale:

Reduction in hand tremors is not an expected outcome of fluoxetine therapy. Fluoxetine is used to treat depression, obsessive-compulsive disorder, some eating disorders, and panic attacks.

Choice C rationale:

Decreased hallucinations is not an expected outcome of fluoxetine therapy. Fluoxetine is not typically used to treat conditions that cause hallucinations.

Choice D rationale:

Improved mood is an expected outcome of fluoxetine therapy. As an antidepressant, fluoxetine works by balancing chemicals in the brain that affect mood and emotions.

A. Psychodrama B. Crisis intervention. C. Dual diagnosis treatment. D. Codependency support.

Correct Answer is C

Explanation

Choice A rationale:

Psychodrama is a therapeutic approach that uses dramatic role play to help clients gain insight into their feelings and behaviors. However, it may not be the most effective for a client with antisocial personality disorder and alcohol dependency.

Choice B rationale:

Crisis intervention is a short-term therapy to stabilize a client during an acute crisis. It may not address the long-term needs of a client with antisocial personality disorder and alcohol dependency.

Choice C rationale:

Dual diagnosis treatment is designed for clients who have a mental health disorder and a substance use disorder. This would be the most appropriate for a client with antisocial personality disorder and alcohol dependency.

Choice D rationale:

Codependency support groups are typically for family members and friends of individuals with substance use disorders. They may not be the most beneficial for the client themselves.

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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?.

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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?.