A nurse is caring for a client with dementia who frequently tries to get out of bed. Which of the following actions should the nurse take?
Turn on the bed alarm.
Maintain the bed in the lowest position.
Place the client in a vest restraint.
Administer a sedative.
The Correct Answer is A
Choice A rationale
A bed alarm is a safety device that alerts staff when a client is attempting to get out of bed, reducing the risk of falls while maintaining the client’s autonomy and dignity.
Choice B rationale
Maintaining the bed in the lowest position minimizes fall risk upon exiting the bed, but it alone does not provide proactive monitoring, thus limiting its preventive effectiveness in dementia clients.
Choice C rationale
Vest restraints physically restrict movement and are associated with risks like pressure injuries or decreased circulation. They are considered a last resort and not routinely recommended for dementia clients.
Choice D rationale
Sedatives increase fall risk due to drowsiness and cognitive impairment, which could exacerbate symptoms in dementia. They are not the preferred intervention for safety concerns in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: An oxygen saturation of 84% indicates severe hypoxemia. Normal oxygen saturation levels are between 95% and 100%. A level this low can impair tissue oxygenation and lead to life-threatening complications like respiratory failure or cardiac arrest.
Choice B rationale: An elevated blood pressure of 168/90 mm Hg, while concerning, does not immediately signify a life-threatening condition. It can be a result of distress or pain and needs management but is not as critical as severe hypoxemia.
Choice C rationale: A respiratory rate of 27/min is elevated but not immediately life-threatening. It indicates the body's effort to compensate for hypoxemia, but the underlying issue of low oxygen saturation is more critical to address.
Choice D rationale: A heart rate of 98/min, although increased, does not indicate a life-threatening condition. The elevation may be due to distress or medication side effects. Managing hypoxemia is more urgent to prevent further complications.
Correct Answer is C
Explanation
Choice A rationale
While activating the fire alarm alerts others, evacuation directly prioritizes client safety by removing them from immediate danger.
Choice B rationale
Closing fire doors helps contain the fire, but client safety requires first removing them from immediate harm before containment actions.
Choice C rationale
Evacuating the room prioritizes removing clients from the source of danger, ensuring their safety from smoke or flames.
Choice D rationale
Extinguishing the fire is critical but secondary to ensuring the client’s safety through evacuation from immediate danger.
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