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 C

Explanation

A. Administer antibiotic therapy to the client. This is a priority intervention, but it is not the first action. Before administration, infection control measures should be in place.

B. Provide the client with analgesics as needed. Pain management is important but is not the first priority. The spread of infection must be controlled immediately.

C. Initiate droplet precautions for the client. Meningococcal meningitis is highly contagious. Droplet precautions (mask, private room) must be initiated immediately to prevent transmission before other interventions.

D. Educate the client about the meningococcal vaccine. Vaccination is a preventive measure but does not address the immediate risk of infection spread.

A. Attach a probe carefully to the client's finger to prevent discomfort. B. Apply a sensor pad to the client's forehead. C. Secure a probe to one of the client's toes. D. Obtain a pulse oximetry reading when peripheral edema has decreased.

Correct Answer is B

Explanation

A. Attach a probe carefully to the client's finger to prevent discomfort. Peripheral edema may impair circulation, leading to inaccurate readings.

B. Apply a sensor pad to the client's forehead. The forehead provides a more accurate reading when peripheral circulation is compromised.

C. Secure a probe to one of the client's toes. Thickened toenails and edema may interfere with an accurate reading.

D. Obtain a pulse oximetry reading when peripheral edema has decreased. The nurse should not delay obtaining an oxygen saturation reading if an alternative site is available.

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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.)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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