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 A

Explanation

Choice A rationale:

Demonstrating a neutral demeanor helps build trust with a client who has paranoid personality disorder. It’s important to avoid showing too much emotion, which could be misinterpreted by the client.

Choice B rationale:

Being vague when answering the client’s questions about instructions could increase the client’s paranoia. Clear and direct communication is essential.

Choice C rationale:

Asking the client why he is suspicious of others could lead to defensive behavior. It’s better to focus on building trust and understanding.

Choice D rationale:

Using an overly friendly approach could be perceived as insincere or manipulative by a client with paranoid personality disorder. A neutral demeanor is more effective.

A. Discourage visitation from the client's family B. Provide a high-stimulation environment for the client. C. Limit the client's need to make decisions. D. Keep the client's room dark at night.

Correct Answer is C

Explanation

Choice A rationale:

Discouraging visitation from the client’s family could increase feelings of isolation and confusion, which could exacerbate delirium.

Choice B rationale:

A high-stimulation environment could overstimulate the client and worsen delirium.

Choice C rationale:

Limiting the client’s need to make decisions can reduce stress and confusion, which can help manage delirium.

Choice D rationale:

Keeping the client’s room dark at night could disrupt the client’s sleep-wake cycle and potentially worsen delirium.

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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?.