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
Active immunity involves the production of antibodies by B lymphocytes in response to antigen exposure, creating a specific and adaptive immune response. This process provides long-lasting immunity.
Choice B rationale
Passive immunity provides temporary immunity through the transfer of pre-formed antibodies, such as via breast milk or immunoglobulin therapy. It does not induce memory B cell activation, so lifelong immunity is not achieved.
Choice C rationale
Active immunity results in long-term immunity by stimulating the immune system to develop memory cells. It does not have a short duration as it enables sustained protection against pathogens.
Choice D rationale
Passive immunity does not involve active antigen recognition by the immune system. However, the immune system is not rendered incapable of recognizing antigens, as this statement incorrectly implies a functional deficiency.
Correct Answer is B
Explanation
Choice A rationale
Decreased blood urea nitrogen (BUN) reflects impaired protein catabolism or renal dysfunction rather than fluid volume status. Normal BUN ranges are 6-20 mg/dL, and deficit elevates this value.
Choice B rationale
Increased hematocrit suggests hemoconcentration due to reduced plasma volume, characteristic of fluid deficit. Normal hematocrit levels range from 38%-46% in women and 40%-54% in men.
Choice C rationale
Decreased urine specific gravity, below 1.005, indicates dilute urine, typically seen in fluid overload rather than deficit. Fluid deficit presents with a value above 1.030, indicating concentrated urine.
Choice D rationale
Increased calcium level, above 10.5 mg/dL, relates to hypercalcemia rather than fluid deficit. It is unrelated to intravascular volume status and may arise from other conditions like hyperparathyroidism.
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