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.
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
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A Rationale: Educating about the importance of proper food handling is important for preventing foodborne illnesses but is not specific to the care of a client with tetanus.
Choice B Rationale: Offering food at least 4 times a day may be necessary for maintaining nutritional support, but it does not address the specific care needs of a client with tetanus.
Choice C Rationale: Anticipating administration of opioids is an important component of the care plan for tetanus. Opioids can help manage muscle spasms and severe pain associated with tetanus.
Choice D Rationale: Providing distraction activities may be beneficial for clients with tetanus to help divert their attention from muscle spasms and discomfort, but it is not the primary intervention.
Correct Answer is ["A","B","C","D","E"]
Explanation
Choice A Rationale: Forgetting names and faces, especially when previously introduced, can be a sign of memory impairment, which is common in Alzheimer's disease. Choice B Rationale: Neglecting bills and financial responsibilities is a sign of impaired executive function, which can occur in Alzheimer's disease.
Choice C Rationale: Mentioning excitement about starting a new job after retirement is a typical sign of Alzheimer's disease.
Choice D Rationale: Repeatedly forgetting that one has already read the newspaper and reading it again can be a sign of short-term memory loss, a characteristic of Alzheimer's disease.
Choice E Rationale: Placing car keys in unusual places and misplacing items like shoes in unexpected locations can be signs of disorientation and memory problems, which are common in Alzheimer's disease.
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