A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client?

Hallways are long distances

The room has an area rug

The bed is in a low position

Outside doors have locks

Answer and Explanation

The Correct Answer is A

A. Hallways are long distances:
Long hallways can be challenging for individuals with dementia due to their potential mobility issues, disorientation, and decreased ability to navigate. Dementia often affects spatial awareness and can lead to confusion, making it difficult for patients to find their way back to their rooms or common areas. Long distances increase the risk of falls and disorientation.

B. The room has an area rug:
Area rugs can present tripping hazards for anyone, especially for individuals with mobility issues, balance problems, or cognitive impairments like dementia. Patients might trip on the edges of the rug, leading to falls and injuries.

C. The bed is in the low position:
Having the bed in a low position is generally considered a safety measure, especially for patients at risk of falls. However, for a patient with dementia, it might be important to strike a balance. Beds that are too low can be difficult for individuals with dementia to get in and out of, potentially leading to falls. It's important to assess the patient's ability to safely get in and out of bed.

D. Outside doors have locks:
Locks on outside doors are essential for the safety of individuals with dementia. Dementia patients are prone to wandering, which can lead them to dangerous situations if they leave the facility unsupervised. Locks on outside doors help prevent wandering, ensuring the patients stay within the secure confines of the facility.

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Correct Answer is A

Explanation

A. Pseudoephedrine
Clients taking phenelzine, which is a monoamine oxidase inhibitor (MAOI) used to treat depression, need to avoid certain over-the-counter medications, especially those containing sympathomimetic amines like pseudoephedrine. Combining MAOIs with sympathomimetic medications can lead to a severe increase in blood pressure, potentially causing a hypertensive crisis.

B. Docusate sodium:
Docusate sodium is a stool softener and is generally safe to use with phenelzine. It does not have significant interactions with MAOIs.

C. Ranitidine:
Ranitidine is an H2 blocker used to reduce stomach acid production. It does not have significant interactions with phenelzine.

D. Ibuprofen:
Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) used for pain and inflammation. While it does not interact directly with phenelzine, individuals taking phenelzine should avoid other medications, especially NSAIDs, that can increase the risk of bleeding due to phenelzine's effects on platelet function. However, this interaction is not as severe as the interaction between phenelzine and sympathomimetic medications like pseudoephedrine.

A. Reassure staff members that the debriefing is confidential. B. Have staff members discuss their involvement in the event. C. Ask staff members to describe their most traumatic memories of the event. D. Provide stress-management exercises to the staff members.

Correct Answer is A

Explanation

A. "Reassure staff members that the debriefing is confidential."
This is an appropriate first step. Ensuring confidentiality creates a safe environment where individuals feel comfortable sharing their experiences and emotions.

B. "Have staff members discuss their involvement in the event."
This can be a part of the debriefing process, but it might not be the first step. Generally, individuals are given the option to share their experiences, but they should not be forced to do so. Some might not be ready to talk about their involvement immediately.

C. "Ask staff members to describe their most traumatic memories of the event."
This might be too intrusive as a first step. It's important to approach discussions about specific traumatic memories with caution and only when individuals are comfortable sharing.

D. "Provide stress-management exercises to the staff members."
This could be a helpful step after ensuring confidentiality and allowing individuals the opportunity to express their feelings. Stress-management exercises can provide valuable coping strategies.

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A nurse in a long-term care facility is assessing a client who has dementia. Which of the following findings should the nurse identify as a risk for this client?

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