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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

A. Papule – A papule is a raised, solid lesion (e.g., a mole) and is palpable, not flat.

B. Vesicle – A vesicle is a fluid-filled blister (e.g., herpes, chickenpox), which is not the case here.

C. Nodule – A nodule is a deep, raised lesion that extends into the dermis or subcutaneous tissue.

D. Macule – A macule is a flat, nonpalpable skin discoloration that is less than 1 cm (e.g., a freckle or petechiae).

A. Provide the client with a referral to a support group. B. Encourage the client to view the body of their partner. C. Reinforce the need for the client to build new relationships. D. Encourage the client to share their thoughts and feelings.

Correct Answer is D

Explanation

A. Provide the client with a referral to a support group. Not the first priority; occurs later in the grieving process.

B. Encourage the client to view the body of their partner. Only appropriate if the client wants to do so.

C. Reinforce the need for the client to build new relationships. Insensitive and premature during initial grief.

D. Encourage the client to share their thoughts and feelings. Therapeutic communication is the first step in grief support, allowing the client to process emotions.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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