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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

Forming a close support network is important in recovery, but it is not the first step. Initial recognition and acceptance of the problem must come first before external support can be effectively utilized.

Choice B rationale

Acknowledging an inability to control drinking is crucial as it represents acceptance of the problem. Without this self-awareness, the individual is unlikely to seek or benefit from treatment options.

Choice C rationale

Incorporating spirituality can be beneficial for some individuals during recovery, providing a sense of purpose and community. However, it is not the initial step. Recognition of the problem must precede other interventions.

Choice D rationale

Agreeing to a prescription for an alcohol use deterrent can be part of the treatment plan. However, the individual must first recognize and accept their inability to control drinking to commit to taking medications as prescribed.

A. Fluctuating level of orientation. B. Consistent state of depression. C. Demonstrates obsessive behaviors. D. Short-term memory loss.

Correct Answer is A

Explanation

Choice A rationale

A fluctuating level of orientation is a hallmark sign of delirium. Delirium is characterized by an acute and fluctuating course of altered mental status, including changes in attention, awareness, and cognition.

Choice B rationale

A consistent state of depression is not indicative of delirium. While depression can affect mental status, it does not typically present with the acute, fluctuating changes seen in delirium.

Choice C rationale

Demonstrating obsessive behaviors is more characteristic of obsessive-compulsive disorder and does not typically indicate delirium.

Choice D rationale

Short-term memory loss can be a feature of many conditions, including dementia, but does not specifically indicate delirium, which is distinguished by its rapid onset and fluctuating nature. .

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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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Naxlex Comprehensive Predictor Exams

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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?