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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Inject the medication deep into the thigh muscle.
This statement is incorrect for subcutaneous heparin administration. Heparin is typically administered subcutaneously in the fatty tissue just under the skin, not into the muscle. Intramuscular injection is not appropriate for heparin.
B. Easy bruising indicates the medication is effective.
This statement is inaccurate. Easy bruising is not an indicator of the effectiveness of heparin. In fact, excessive bruising can be a side effect of anticoagulant therapy, indicating a potential issue with bleeding or clotting.
C. Expect stools to become black and tarry.
This statement is more relevant to medications like iron supplements or upper gastrointestinal bleeding. It is not a common side effect of subcutaneous heparin.
D. Use a soft bristle toothbrush.
This statement is correct. It is important for individuals on anticoagulant therapy, such as heparin, to use a soft bristle toothbrush to minimize the risk of bleeding and gum irritation. Hard bristle toothbrushes can cause gum bleeding, especially in individuals with a tendency for bleeding due to anticoagulant use.
Correct Answer is ["7"]
Explanation
To give the correct dose of amoxicillin 350 mg PO, the nurse needs to calculate how many ml. of the available solution are equivalent to that amount. The available solution has a concentration of 250 mg/5 mL, which means that every 5 ml. contain 250 mg of amoxicillin. To find out how many ml. are needed for 350 mg, the nurse can use a proportion:
250 mg/5 mL = 350 mg/x mL
Cross-multiplying and solving for x, we get:
x = (350 mg x 5 mL) / 250 mg
x = 7 ml.
Therefore, the nurse should administer 7 ml. of the amoxicillin solution.
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