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A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?

Request a consult with recreational therapy.

Lower the window shade in the client's room.

Place the client in a room close to the nurses' station.

Obtain a PRN prescription for a vest restraint.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Recreational therapy may be beneficial, but it is not the primary intervention to reduce the risk of falls.

Choice B rationale

Lowering the window shade could help with sensory overload, but it does not directly address fall prevention.

Choice C rationale

Placing the client near the nurses' station allows for closer monitoring and quicker intervention, which can help prevent falls.

Choice D rationale

Vest restraints should only be used as a last resort after other less restrictive measures have been tried and found ineffective.

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Correct Answer is B

Explanation

Choice A rationale

Reaction formation is a defense mechanism where an individual behaves in a manner opposite to their true feelings or desires. It does not involve physical manifestations of anxiety.

Choice B rationale

Somatization involves the transformation of anxiety into physical symptoms, such as pain, fatigue, or gastrointestinal issues, without a medical cause. This is a way the body expresses psychological distress through physical symptoms.

Choice C rationale

Sublimation is a defense mechanism where unacceptable impulses or desires are transformed into socially acceptable activities or behaviors. It is not related to physical manifestations of anxiety.

Choice D rationale

Intellectualization involves using logic and reasoning to avoid emotional stress. It does not involve transforming anxiety into physical symptoms. .

A. A client who is repeatedly approaching the nurses' station to request medication for his anxiety. B. A client who is standing in her room, yelling obscenities, and throwing her clothes. C. A client who has bipolar disorder and is continuously pacing at the end of the hall. D. A client in the dayroom who is screaming at other clients about what is on the television.

Correct Answer is B

Explanation

Choice A rationale

While this client may need attention, the behavior is not immediately dangerous.

Choice B rationale

This client requires immediate attention due to the risk of harm to herself and others through throwing objects and yelling, which indicates potential for escalation.

Choice C rationale

Pacing, although concerning, does not pose an immediate risk of physical harm compared to Choice B.

Choice D rationale

The client is disruptive but not immediately dangerous compared to the client in Choice B who poses a more direct risk.

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A nurse is caring for a client who has dementia and is experiencing an increased number of falls.Which of the following actions should the nurse take?

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A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?