A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

Apply a vest restraint on the client.

Place the client in bed with the two side rails raised.

Place a seat alarm in the client's chair.

Administer lorazepam the client.

Answer and Explanation

The Correct Answer is C

Choice A Rationale: Applying a vest restraint should not be the first action and should only be considered as a last resort after other alternatives have been explored.

Choice B Rationale: Placing the client in bed with two side rails raised may restrict the client's mobility and is not the first choice for managing agitation.

Choice C Rationale: Placing a seat alarm in the client's chair is the first action to take because it allows the nurse to monitor the client's movements and respond promptly to any attempts to get out of the chair while ensuring safety.

Choice D Rationale: Administering lorazepam should not be the first action and should only be considered after non-pharmacological interventions have been attempted

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Correct Answer is C

Explanation

Choice A Rationale: Repositioning may be important for preventing complications, but it does not explain the pain described by the client.

Choice B Rationale: A continual inflammatory process is not typically the cause of the pain described by the client with a spinal cord injury.

Choice C Rationale: Nerve damage in the spinal cord is a common cause of neuropathic pain with these characteristics.

Choice D Rationale: Telling the client that the pain will go away in 2 weeks without further assessment or explanation is not accurate and may raise unrealistic expectations.

A. Ask the spouse what she knows about dementia care options. B. Suggest placement into a long-term care facility. C. Teach the spouse about adult day care as a possible respite. D. Suggest that the spouse consult with the physician for antianxiety drugs. E. Offer ideas for ways to distract or redirect the patient.

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

Explanation

Choice A Rationale: Asking the spouse what she knows about dementia care options is a good starting point to assess her knowledge and provide information and resources, and empowering her to make informed decisions.

Choice B Rationale: Suggesting placement into a long-term care facility should not be the first option but can be explored if necessary, based on the client's condition and the caregiver's needs.

Choice C Rationale: Teaching the spouse about adult day care as a possible respite is a way of offering support and relief for the caregiver, who may experience stress and burnout from the constant demands of caring for a patient with AD.

Choice D Rationale: Suggesting that the spouse consult with the physician for antianxiety drugs is not helpful, as it may imply that the spouse's feelings are abnormal or that she needs medication to cope.

Choice E Rationale: Offering ideas for ways to distract or redirect the patient is not relevant to the spouse's needs, as it does not address her exhaustion and worry.

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A nurse is caring for a client who has dementia. The client is agitated and is having difficulty staying in his chair. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

I client with a spinal cord injury reports hot, burning, tingling, pain that shoots down his extremities. When the client asks why this occurs, what is the nurse's best response?

Correct Answer is C

Explanation

The spouse of a 67-yr-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take at this time? Select All that Apply

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

Explanation

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