A nurse is caring for an older adult client who has dementia and whose family reports he gets up and wanders around at night. Which of the following actions should the nurse take?
Keep the client's personal items within reach.
Tell the family that someone should plan to stay with the client.
Place the client in a quiet room at the end of the hallway.
Provide bright lighting in the client's room at night.
The Correct Answer is A
A. Keep the client's personal items within reach. Keeping the client's personal items within reach can provide a sense of familiarity and comfort, which may reduce anxiety or disorientation, thereby decreasing the tendency to wander.
Incorrect options:
B. "Tell the family that someone should plan to stay with the client.": While family involvement is important, this suggestion may not always be feasible. Additionally, it’s the nurse’s role to ensure the safety of the client within the facility.
C. "Place the client in a quiet room at the end of the hallway.": Isolating the client may increase confusion and feelings of disorientation.
D. "Provide bright lighting in the client's room at night.": Bright lights at night can disrupt sleep and may cause further disorientation. Dim or soft lighting or use of night lights in the room is generally more appropriate to promote restful sleep.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Discontinuing the existing IV infusion is the priority when signs of infection or inflammation are present at the site. This action helps prevent the spread of infection and allows for a thorough assessment of the site.
B. Inserting an IV catheter in the opposite extremity is not the first step. Before considering a new IV site, it's crucial to address the issue with the current site. Starting a new IV line before addressing the potential infection could lead to further complications.
C. Applying warm, moist compresses to the site is not the first action. While warm compresses can be used to promote blood flow and comfort, the priority is to discontinue the current infusion and assess for infection or inflammation.
D. Elevating the extremity is not the first action in response to signs of infection or inflammation at an IV site. The priority is to discontinue the infusion and assess the site for potential complications.
Correct Answer is ["D","E"]
Explanation
A. Place the child in prone position:
Placing the child in a prone position (lying face down) during a seizure can obstruct the airway and lead to potential breathing difficulties.
B. Restrain the child:
Restraining a child during a seizure can cause injury or increase agitation. It's important to allow the child to move safely and avoid trying to hold them down.
C. Place a tongue depressor in the child's mouth:
It is not recommended to place anything, including a tongue depressor, in the child's mouth during a seizure. Doing so can cause injury to the child's teeth or oral structures.
D. Clear the area of hard objects:
Removing hard or sharp objects from the vicinity helps prevent injury to the child during the seizure.
E. Loosen restrictive clothing:
Loosening any tight clothing, especially around the neck, chest, or waist, allows the child to breathe more easily and reduces potential constriction during the seizure.
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