A nurse is caring for a patient who has dementia.
What intervention should the nurse take to minimize the risk of injury to the patient?
Use a bed exit alarm system.
Raise four side rails while the patient is in bed.
Apply one soft wrist restraint.
Dim the lights in the patient’s room.
The Correct Answer is A
Choice A rationale
Using a bed exit alarm system is a common intervention to minimize the risk of injury in patients with dementia. These systems alert staff when a patient attempts to leave the bed, allowing for timely intervention to prevent falls.
Choice B rationale
Raising four side rails while the patient is in bed is not a recommended practice. This could be considered a form of restraint and could increase the risk of injury if the patient attempts to climb over the rails.
Choice C rationale
Applying one soft wrist restraint is not a recommended practice for patients with dementia. Restraints should be used as a last resort and only when necessary for the patient’s safety.
Choice D rationale
Dimming the lights in the patient’s room is not a recommended practice to minimize the risk of injury in patients with dementia. Adequate lighting can help prevent falls and other accidents.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Tuberculosis is a serious infectious disease that affects the lungs. However, it does not typically cause lung hyperinflation.
Choice B rationale
Bronchitis is an inflammation of the bronchial tubes. While it can cause symptoms similar to those described, it does not typically cause lung hyperinflation or localized pneumonia in the left upper lobe.
Choice C rationale
Pneumonia is an infection that inflames the air sacs in one or both lungs. The client’s symptoms of a productive cough with thick yellow sputum, crackles in the left upper lobe, and decreased breath sounds at bases bilaterally are consistent with pneumonia. The chest x-ray showing left upper lobe pneumonia confirms this diagnosis.
Choice D rationale
Asthma is a condition in which a person’s airways become inflamed, narrow and swell, and produce extra mucus, which makes it difficult to breathe. While asthma can cause lung hyperinflation, it does not typically cause localized pneumonia in the left upper lobe.
Correct Answer is ["A","B"]
Explanation
Choice A rationale
When a patient is placed on isolation precautions, the nurse should wear an N95 mask when caring for the patient. This is to protect the nurse from airborne particles that may be present in the patient’s environment.
Choice B rationale
Another important action the nurse should take is to place a container for soiled linens inside the patient’s room. This is to prevent the spread of infection from the patient’s room to other areas of the healthcare facility.
Choice C rationale
Wearing a sterile, water-resistant gown if within 3 feet of the patient is not necessary unless the patient has a condition that requires contact precautions, such as MRSA or VRE. In general, isolation precautions do not require the use of a sterile gown unless performing a sterile procedure.
Choice D rationale
Ensuring the patient’s room is well-ventilated is important for certain types of isolation precautions, such as airborne precautions for tuberculosis. However, it is not a standard action for all isolation precautions.
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