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 A
Explanation
Choice A rationale
The client’s symptoms of itching, anxiety, a flushed face, and hives after the initiation of a blood transfusion are indicative of an allergic reaction. These symptoms suggest that the client may be having a reaction to the transfused blood, which can occur if the client’s immune system reacts against the blood cells or other components of the transfused blood.
Choice B rationale
While some side effects can occur during a blood transfusion, the symptoms the client is experiencing are not normal side effects of the procedure. Normal side effects might include a slight fever or chills.
Choice C rationale
Although the client is experiencing anxiety, this is likely a symptom of the allergic reaction rather than an indication of an anxiety disorder.
Choice D rationale
Hypersensitivity to the IV gauge material is unlikely to cause the symptoms the client is experiencing. Hypersensitivity reactions to medical device materials are rare and would not typically cause systemic symptoms like itching and hives.
Correct Answer is B
Explanation
Choice A rationale
Inserting the catheter at a 45-degree angle is not recommended for an older adult client with fragile skin. A lower angle of insertion is usually more appropriate.
Choice B rationale
Positioning the client’s arm in a dependent position can help engorge the veins, making it easier to insert the IV catheter.
Choice C rationale
Removing excess hair from the insertion site is not the first action the nurse should take. While it’s important to have a clean and clear insertion site, positioning the client’s arm correctly is a more immediate concern.
Choice D rationale
Initiating IV therapy in the veins of the hand is not the first action the nurse should take. While the veins of the hand can be used for IV insertion, positioning the client’s arm correctly is a more immediate concern.
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