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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "Talking about the traumatic experience is recommended."
This statement is generally correct. Many therapeutic approaches for PTSD, such as cognitive-behavioral therapy (CBT) and exposure therapy, involve talking about the traumatic experience in a controlled and supportive environment. However, the timing and method of discussing the trauma should be guided by a mental health professional.
B. "Response prevention is an effective treatment for PTSD."
This statement is incorrect. Response prevention is a therapeutic technique often used in the treatment of anxiety disorders like obsessive-compulsive disorder (OCD). It involves preventing the usual response to a trigger. However, for PTSD, exposure therapy, cognitive restructuring, and EMDR (Eye Movement Desensitization and Reprocessing) are more common therapeutic approaches.
C. "You should try to limit the number of hours that you sleep each day."
This statement is incorrect. Adequate sleep is crucial for overall mental and physical health, and disrupting sleep patterns can worsen symptoms of PTSD. Sleep disturbances are common in PTSD, and part of managing the disorder often involves addressing sleep problems.
D. "Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD."
This statement is generally correct. Avoiding triggers that bring back memories of the trauma is a common coping strategy. However, while avoidance might provide short-term relief, it's not a long-term solution. Evidence-based therapies often involve confronting and processing these triggers in a safe and controlled way, under the guidance of a therapist.
Correct Answer is B
Explanation
A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.
B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.
C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.
D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.
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