A confused elderly patient in a long-term care facility attempts to wander at night. Which intervention is most appropriate?
Select one:
Apply physical restraints at bedtime
Restrict fluids after dinner
Administer a sedative before sleep
Use a bed alarm and place the patient near the nurse station
The Correct Answer is D
A. Restraints should be avoided whenever possible due to risks of injury, increased agitation, and ethical concerns.
B. Limiting fluids may lead to dehydration and does not address the wandering behavior directly.
C. Sedatives can increase confusion and fall risk in elderly patients and should be used cautiously.
D. This is a safe, least restrictive way to monitor and respond promptly to wandering behavior, ensuring patient safety while preserving dignity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increasing the client’s sodium intake is contraindicated. Sodium contributes to fluid retention, which can worsen ascites in clients with cirrhosis.
B. Decreasing the client’s fluid intake is correct. Fluid restriction is often recommended for clients with ascites to help control fluid accumulation in the abdominal cavity and reduce discomfort.
C. Increasing the client’s saturated fat intake is not advisable, as it can contribute to further liver damage and complications in clients with liver disease.
D. Decreasing the client’s carbohydrate intake is unnecessary unless blood glucose control is an issue. Clients with cirrhosis often need adequate carbohydrates for energy, especially since protein intake may be limited to prevent hepatic encephalopathy.
Correct Answer is C
Explanation
A. Stomatitis (inflammation of the mouth) can occur with chemotherapy or radiation but is not directly related to thrombocytopenia.
B. This is typically associated with neurologic disorders or electrolyte imbalances, not low platelet counts.
C. Thrombocytopenia is a low platelet count, which impairs the blood’s ability to clot. This puts the patient at high risk for bruising, prolonged bleeding, spontaneous bleeding, and internal hemorrhage.
D. While a headache may occur for various reasons, it is not a hallmark symptom or direct consequence of thrombocytopenia.
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