A home health nurse is providing education for the family of a client who has dementia. Which of the following interventions should the nurse recommend?
Place a soft rug in front of the client's chair.
Set the client's water heater at 140° F.
Encourage the client to take a 1 hr nap in the afternoon.
Limit fluid intake after the client's evening meal.
The Correct Answer is C
Choice A reason: Placing a soft rug in front of the client’s chair increases the risk of tripping and falling. Clients with dementia often have impaired judgment, coordination, and gait instability. Loose rugs are a well-known environmental hazard in home safety assessments, and therefore this intervention is unsafe.
Choice B reason: Setting the water heater at 140° F is dangerous because clients with dementia may not recognize the risk of burns. Safe water heater settings are typically recommended at or below 120° F to prevent scalding injuries. High temperatures pose a significant safety risk for cognitively impaired individuals.
Choice C reason: Encouraging a 1-hour nap in the afternoon is beneficial. Clients with dementia often experience fatigue, irritability, and sundowning (worsening confusion in the evening). A structured rest period helps reduce agitation, improves mood, and supports overall functioning. This intervention promotes both safety and comfort.
Choice D reason: Limiting fluid intake after the evening meal can lead to dehydration and urinary tract infections. While nighttime incontinence may be a concern, restricting fluids is not recommended because hydration is critical for cognitive and physical health. Instead, toileting schedules and protective measures should be used.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Selective inattention occurs in moderate anxiety, where the client begins to block out or ignore certain stimuli due to difficulty focusing. It is not characteristic of mild anxiety, where awareness is still intact.
Choice B reason: Urinary frequency is a physical manifestation of severe anxiety due to autonomic nervous system activation. It is not expected in mild anxiety.
Choice C reason: Sharpened perceptions are characteristic of mild anxiety. The client is more alert, attentive, and able to focus better on the environment. Mild anxiety can enhance problem-solving and concentration.
Choice D reason: Voice tremors are associated with moderate to severe anxiety, where physiological symptoms become more pronounced. They are not typical of mild anxiety.
Correct Answer is ["A","D"]
Explanation
Choice A reason: Offering the client a PRN dose of lorazepam is appropriate because benzodiazepines are often prescribed for acute agitation and anxiety. Administering medication can help de-escalate the situation, reduce the risk of violence, and restore calm. This intervention directly addresses the client’s agitation and promotes safety for both the client and others.
Choice B reason: Asking open-ended questions during an episode of acute agitation is not appropriate. Open-ended questions require thought and elaboration, which can increase frustration and escalate aggression. In crisis situations, communication should be simple, direct, and focused on safety rather than exploration.
Choice C reason: Standing directly in front of the client is unsafe because it places the nurse in a vulnerable position if the client becomes physically aggressive. The nurse should maintain a safe distance and stand at an angle to reduce the risk of harm.
Choice D reason: Moving others away from the client is correct because it protects the safety of the group. Removing potential targets of aggression reduces the risk of injury and helps de-escalate the environment. This is a critical safety measure in managing violent behavior.
Choice E reason: Speaking in an aggressive tone of voice is inappropriate because it escalates tension and may provoke further aggression. The nurse should use a calm, firm, and non-threatening tone to de-escalate the situation.
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