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.

Answer and Explanation

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.

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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.

A. Record the client’s behavior every 15 min while in restraints. B. Secure the restraint to the client’s bed rail using a slip knot. C. Raising all four bedrails to keep a client in bed is not considered a restraint. D. The nurse should assess a restrained client once every 2 hr.

Correct Answer is A

Explanation

Choice A reason: Recording the client’s behavior every 15 minutes while in restraints is correct because frequent documentation ensures safety, monitors the client’s physical and psychological status, and provides evidence that restraints are being used appropriately.

Choice B reason: Securing restraints to the bed rail is unsafe because bed rails move and can cause injury. Restraints should be secured to the bed frame using a quick-release knot, not a slip knot, to allow rapid removal in emergencies.

Choice C reason: Raising all four bedrails is considered a restraint if it restricts the client’s freedom of movement. This statement is incorrect because it misrepresents restraint guidelines.

Choice D reason: Assessing a restrained client only once every 2 hours is insufficient. Clients must be assessed at least every 15 minutes for safety, circulation, and comfort. Two-hour checks would not meet safety standards.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing mild anxiety. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A charge nurse is planning an in-service for a group of newly licensed nurses about the use of restraints. Which of the following information should the nurse include?

Correct Answer is A

Explanation

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