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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["4"]
Explanation
To administer the correct dose of duloxetine, which is 120 mg, when only 30 mg capsules are available
By dividing the total daily dose needed (120 mg) by the strength of each capsule (30 mg), we find that 4 capsules are needed to achieve the 120 mg dosage.
Therefore, the nurse should administer four 30 mg capsules of duloxetine to the client.
Correct Answer is ["B","C","D","E"]
Explanation
A. Being married is generally considered a protective factor against suicide. Married individuals often have social support and a sense of belonging, which can reduce suicide risk. Therefore, this would not be identified as a risk factor for suicide.
B. Alcohol use disorder is a significant risk factor for suicide. Alcohol can impair judgment, increase impulsivity, and exacerbate underlying mental health issues. It is associated with higher rates of suicidal ideation and attempts.
C. Family history of suicide, including among siblings, is a known risk factor. Exposure to suicide within the family can contribute to feelings of hopelessness, increase perceived acceptability of suicide, and impact mental health negatively.
D. Access to firearms is a well-established risk factor for completed suicide. Firearms are highly lethal, and their presence increases the likelihood of a fatal suicide attempt compared to other means.
E. Terminal illness, including conditions like terminal liver cancer, can contribute to feelings of hopelessness and despair, potentially increasing suicide risk. The distress related to the prognosis and physical symptoms can exacerbate mental health issues.
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