A nurse is caring for a client who has dementia and frequently tries to get out of bed. Which of the following actions should the nurse take? (Select all that apply.)
Turn on the bed alarm.
Maintain the bed in the lowest position.
Place the client in a vest restraint.
Administer a sedative.
Encourage the family to stay with the client.
Correct Answer : A,B,E
A. Turn on the bed alarm. A bed alarm alerts staff when the client attempts to get up, helping prevent falls.
B. Maintain the bed in the lowest position. Keeping the bed low reduces the risk of injury in case the client attempts to get up unassisted.
C. Place the client in a vest restraint. Restraints should be used only as a last resort after less restrictive measures fail. They can cause distress and increase agitation in clients with dementia.
D. Administer a sedative. Sedatives can increase confusion, risk of falls, and respiratory depression, making them an inappropriate first-line intervention.
E. Encourage the family to stay with the client. Having familiar caregivers present can provide reassurance and reduce agitation, making it a beneficial intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Picture yourself in one of your favorite places." This statement is related to visualization, which is a different technique, not specifically meditation.
B. "Choose a word to help focus your attention." Mantra meditation involves repeating a word or phrase to enhance focus and promote relaxation.
C. "Quickly inhale deeply and hold your breath for 30 seconds." Holding the breath for 30 seconds can increase anxiety rather than reduce it. Meditation encourages slow, deep breathing, not breath-holding.
D. "Plan for 1 hour of meditation for each session." Meditation can be beneficial even if done for a few minutes. For beginners, shorter sessions (e.g., 5–10 minutes) are recommended.
Correct Answer is A
Explanation
A. Ask the client to describe their feelings. Encouraging the client to express their emotions allows the nurse to assess their concerns and provide appropriate support. This is a key principle of therapeutic communication.
B. Discuss the competency of the surgeon with the client. While the surgeon's competency may help reassure the client, the nurse should not comment on the surgeon’s skill. Instead, the nurse should focus on the client's emotions and provide factual information about the procedure if needed.
C. Inform the client that others have had the procedure without problems. This response dismisses the client’s concerns rather than addressing their feelings. Each client’s experience is unique, and reassurance should be based on listening and providing accurate information.
D. Ask the client why they are experiencing anxiety. Asking “why” can make the client feel defensive. Instead, the nurse should use open-ended questions, such as "Can you tell me more about your concerns?", which encourages discussion without judgment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
