A nurse in a long-term care facility is admitting a client who has dementia.
Which of the following actions should the nurse take to reduce the risk for client injury?

Assist the client to the toilet frequently.

Raise the side rails up when the client is in bed.

Place the bedside table at the foot of the bed.

Keep the television on during the night.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Clients with dementia often experience difficulties with memory, cognition, and orientation, which can lead to increased risk of falls and injuries, especially when trying to perform activities of daily living such as using the toilet. Assisting the client to the toilet frequently helps prevent accidents and reduces the risk of injury from falls. Timely toileting can also improve the client's comfort and overall quality of life.

Choice B rationale:

Raising the side rails up when the client is in bed can create a physical barrier, but it is not a recommended method to prevent falls in clients with dementia. In fact, it can pose a risk by confining the client and may lead to attempts to climb over the rails, resulting in falls and injuries.

Choice C rationale:

Placing the bedside table at the foot of the bed does not directly address the client's safety needs. While it might be a matter of personal preference or convenience, it does not significantly impact the client's risk of injury.

Choice D rationale:

Keeping the television on during the night does not address the client's physical safety. While it may provide entertainment or a familiar environment, it does not mitigate the risk of falls or injuries, which is the primary concern when caring for clients with dementia.

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Correct Answer is A

Explanation

Choice A rationale:

A swollen area on the calf can indicate deep vein thrombosis (DVT), which is a serious complication of immobility. Immobilization can lead to blood stasis in the veins, increasing the risk of clot formation. DVT can result in severe complications, such as pulmonary embolism, making it a critical concern that requires immediate attention.

Choice B rationale:

Increased blood pressure is not a direct complication of immobility. However, immobility can contribute to hypertension over time due to factors such as weight gain and reduced cardiovascular fitness. While hypertension is a concern, it is not an acute complication of immobility that necessitates immediate intervention.

Choice C rationale:

Decreased serum calcium levels are not a direct complication of immobility. Immobility can lead to bone density loss and potential fractures due to reduced weight-bearing activities, but it does not cause an acute decrease in serum calcium levels.

Choice D rationale:

Urinary frequency is not a typical complication of immobility. Immobility can affect the urinary system, potentially leading to urinary stasis and increased risk of urinary tract infections, but urinary frequency is not a direct result of immobility.

A. I am not allowed to change my mind once I sign this document." B. "I should discuss this document with my family after I sign it." C. "My partner needs to be present when I sign this document." D. "An attorney will need to notarize this document for it to be valid."

Correct Answer is B

Explanation

An advance directive is a legal document that allows a client to express their wishes regarding medical care in case they become incapacitated. The client should discuss this document with their family before signing it, so that they are aware of the client's preferences and can respect them. The other options are incorrect because the client can change their mind at any time, their partner does not need to be present, and an attorney does not need to notarize the document.

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A nurse in a long-term care facility is admitting a client who has dementia.Which of the following actions should the nurse take to reduce the risk for client injury?

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A nurse in a long-term care facility is admitting a client who has dementia.
Which of the following actions should the nurse take to reduce the risk for client injury?