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 B
Explanation
Choice A rationale
Inserting the suction catheter while the patient is swallowing is not the recommended technique for nasotracheal suctioning. This could cause discomfort and potentially lead to aspiration.
Choice B rationale
Applying intermittent suction when withdrawing the catheter is the correct technique for nasotracheal suctioning. This helps to remove secretions effectively while minimizing trauma to the nasal and tracheal mucosa.
Choice C rationale
Placing the catheter in a location that is clean and dry for later use is not a recommended practice. After suctioning, the catheter should be properly cleaned or disposed of to prevent infection.
Choice D rationale
Holding the suction catheter with their clean, non-dominant hand is not a recommended practice. The nurse should use clean gloves and proper hand hygiene when performing nasotracheal suctioning to prevent infection.
Correct Answer is B
Explanation
Choice A rationale
While colonoscopy is a screening method for colon cancer, it is not typically recommended to begin at age 60 for individuals at average risk. Instead, colonoscopy screening is usually recommended to begin at age 50 and continue every 10 years if no polyps are found.
Choice B rationale
The recommendation for an average risk individual for colon cancer is to have a fecal occult blood test every year. This test checks for hidden blood in the stool, which can be an early sign of cancer.
Choice C rationale
Sigmoidoscopy every 10 years is another screening option for colon cancer. However, it only examines the rectum and lower third of the colon, whereas a colonoscopy examines the entire colon.
Choice D rationale
Blood tests are not typically used as a primary screening method for colon cancer. They may be used in conjunction with other tests, but a blood sample alone is not sufficient for screening.
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