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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale

Carrying a patient’s soiled linens out of the room in a mesh linen bag is not the most effective way to prevent the spread of infection. While it’s important to handle soiled linens properly to avoid contaminating oneself or the environment, this action alone does not have a significant impact on preventing the spread of infection among a group of patients.

Choice B rationale

Placing a patient who has tuberculosis in a room with negative-pressure airflow is a key measure in preventing the spread of this airborne infection. Negative-pressure rooms prevent

contaminated air from escaping the room and spreading to other areas, thereby protecting other patients and healthcare workers.

Choice C rationale

Providing disposable plates and utensils for a patient who is HIV-positive is not necessary for preventing the spread of infection. HIV is not transmitted through casual contact or through sharing food or utensils.

Choice D rationale

Disposing of a patient’s blood-saturated dressing in a trash bag inside a second trash bag is a good practice for handling biohazardous waste, but it is not the most effective measure for preventing the spread of infection among a group of patients.

A. A client who has a prescription for a nasogastric tube refuses it, and the nurse complies with the client’s wishes. B. A client who has a do-not-resuscitate (DNR) order experiences a cardiac arrest, and the nurse does not perform CPR despite requests from the client’s family. C. A client who is about to undergo a painful procedure receives pain medication 30 minutes before the procedure, as the nurse had previously promised. D. A client who is unaware of their recent cancer diagnosis asks the nurse if they have cancer, and the nurse responds affirmatively.

Correct Answer is D

Explanation

Choice A rationale

This choice represents the ethical principle of autonomy, which respects the client’s rights and preferences in their healthcare decisions.

Choice B rationale

This choice demonstrates the ethical principle of fidelity, which involves keeping promises and commitments, such as honoring a DNR order.

Choice C rationale

This choice reflects the ethical principle of beneficence, which involves taking positive actions to help others and promote the well-being of clients.

Choice D rationale

This choice represents the ethical principle of veracity, which involves truth-telling. In this situation, the nurse is being truthful to the client about their cancer diagnosis, thus demonstrating veracity.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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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?