A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?
Place the client's bed at the lowest height.
Request a prescription for a nightly sedative.
Assist the client with toileting at least once every 4 hours.
Turn off all lights in the client's room at night.
The Correct Answer is A
Choice A reason: Placing the client's bed at the lowest height is a safety intervention that minimizes the risk of injury from falls, which is particularly important for clients with dementia who may have impaired mobility or judgment. Lowering the bed height can reduce the severity of an injury if a fall does occur. Additionally, it can facilitate easier access for the client to get in and out of bed with less assistance.
Choice B reason: Requesting a prescription for a nightly sedative is not typically recommended as a first-line intervention for clients with dementia. Sedatives can increase the risk of confusion, falls, and can worsen cognitive impairment in the elderly. Non-pharmacological approaches are preferred for managing sleep disturbances in dementia patients.
Choice C reason: Assisting the client with toileting at least once every 4 hours is an important intervention to maintain hygiene and comfort, as well as to prevent urinary tract infections and skin breakdown. However, the frequency of toileting assistance should be individualized based on the client's needs and level of incontinence.
Choice D reason: Turning off all lights in the client's room at night is not advisable as some clients with dementia may experience increased confusion or agitation in complete darkness. A nightlight or low-level lighting can provide a safer environment and help to orient the client during nighttime hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This statement encourages the client's involvement by offering assistance in creating a personalized list of preferred foods, which can then be discussed with the dietitian. It promotes a collaborative approach to the dietary plan, allowing the client to have a say in their food choices, which is essential for long-term adherence and management of type 2 diabetes.
Choice B reason: While this statement shows empathy, it does not actively encourage the client's involvement in their care. Understanding the challenges is important, but it is more beneficial to empower the client to take an active role in managing their dietary choices.
Choice C reason: This statement is factual, as managing diabetes does require accommodations. However, it does not directly encourage the client's involvement. Instead, it could be more encouraging by suggesting ways the client can participate in making those accommodations.
Choice D reason: Informing the client that the dietitian will provide the best food choices is reassuring but does not facilitate the client's involvement. It positions the dietitian as the sole decision-maker rather than including the client as an active participant in their dietary planning.
Correct Answer is C
Explanation
Choice A reason : A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.
Choice B reason : A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.
Choice C reason : A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.
Choice D reason : A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.