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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Encouraging the client to attend a daily exercise program on the unit is beneficial for the client’s health, but it does not demonstrate the ethical principle of veracity, which involves truthfulness and honesty.
Choice B rationale:
Maintaining the client’s confidentiality about a substance use disorder is an important aspect of nursing care, but it demonstrates the ethical principle of confidentiality, not veracity.
Choice C rationale:
Reinforcing information on the potential adverse effects of a medication with the client is an example of veracity. The nurse is being truthful and transparent about the potential risks associated with the medication.
Choice D rationale:
Respecting the client’s right to refuse to attend a group therapy session demonstrates the ethical principle of autonomy, not veracity.
Correct Answer is B
Explanation
Choice A rationale:
This statement is incorrect. People with bulimia nervosa often consume large amounts of food in a short period of time, known as binge eating.
Choice B rationale:
This statement is correct. Despite the binge-purge cycle, individuals with bulimia nervosa can maintain an average or ideal body weight, making the disorder less noticeable.
Choice C rationale:
This statement is incorrect. While self-induced vomiting is a common method of purging in bulimia nervosa, other methods such as excessive exercise, fasting, or misuse of laxatives, diuretics, or enemas can also be used.
Choice D rationale:
This statement is incorrect. While bulimia nervosa can lead to various health complications, it is not directly associated with the development of diabetes mellitus.
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