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?

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

Request a consult with recreational therapy.

Lower the window shade in the client's room.

Obtain a PRN prescription for a vest restraint.

Answer and Explanation

The Correct Answer is A

A.   This is a proactive measure to enhance supervision and quick response to any signs of agitation, wandering, or attempts to get out of bed without assistance. Being closer to the nurses' station allows for more frequent monitoring and timely intervention to prevent falls.
B.   Recreational therapy can play a significant role in enhancing the client's physical and cognitive abilities through tailored activities. Activities such as balance exercises, supervised walks, or engaging in structured programs can help improve mobility and reduce the risk of falls.
C.   Lowering the window shade can reduce distractions and provide a calmer environment for the client. Excessive light or glare can sometimes contribute to confusion or disorientation in individuals with dementia. A more subdued environment can potentially decrease agitation and wandering behaviors, indirectly lowering the risk of falls.

D.   The use of physical restraints, such as vest restraints, is generally discouraged in clients with dementia due to the potential for physical and psychological harm. Restraints can increase agitation, anxiety, and risk of injury, and they do not address the underlying causes of falls. The focus should be on environmental modifications, supervision, and non-pharmacological interventions.

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Correct Answer is ["A","C"]

Explanation

A. Individuals with ASPD often exhibit manipulative behaviors to exploit others for their own gain or pleasure. They may be deceitful and use charm or manipulation to achieve their goals.
B. This finding is not typically associated with ASPD. Instead, individuals with ASPD tend to focus on immediate gratification and may have difficulty with long-term planning or sustained attention.
C. People with ASPD typically have a reduced ability to empathize with others. They may disregard the feelings, rights, and sufferings of others, and show little remorse for their actions.
D. Splitting refers to a defense mechanism where individuals tend to view people, situations, or events as either all good or all bad. While this can occur in personality disorders like borderline personality disorder, it is not a characteristic feature of ASPD.
E. Impulsivity is a common trait in individuals with ASPD. They often act without considering the consequences of their actions, leading to risky behaviors such as substance abuse, reckless driving, or criminal activities.

A. Witness the client signing the form. B. Discuss alternative treatment options with the client. C. Determine the client is competent to give consent. D. Discuss the benefits of ECT with the client.

Correct Answer is A

Explanation

A. One of the nurse's responsibilities during the informed consent process is to witness the client signing the consent form. This ensures that the client voluntarily agrees to undergo ECT after receiving adequate information about the procedure, its risks, benefits, and alternatives. By witnessing the signature, the nurse confirms that the client's consent is documented appropriately and legally.
B. Nurses may provide general information about ECT and its alternatives, but the detailed discussion about treatment options and their implications usually occurs during the consultation with the provider.
C. Determining if a client is competent to give consent is a legal determination typically made by a healthcare provider or a legal representative, not the nurse.
D. It is not the nurse's role to discuss the specific benefits of ECT, as these discussions are the responsibility of the healthcare provider leading the client's care.

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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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Correct Answer is A

Explanation

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