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 B
Explanation
Choice A reason : While eating fresh fruits and vegetables is generally healthy, it does not specifically indicate an understanding of AIDS-related teaching. Some fruits and vegetables need to be carefully handled to avoid potential infections.
Choice B reason : Wearing gloves and washing hands after changing a cat's litter box is correct as it helps prevent the transmission of infections, such as toxoplasmosis, which can be particularly harmful to individuals with AIDS.
Choice C reason : Taking clothes to the dry cleaners for sterilization is unnecessary and does not reflect an understanding of AIDS-related precautions.
Choice D reason : Wiping up areas soiled with body fluids with alcohol and disposing of the trash is a good practice for infection control, but it is not as directly related to the client's understanding of AIDS-specific precautions as choice b.
Correct Answer is A
Explanation
Choice A reason: Administering oxygen at 2 L/min is appropriate for clients with emphysema who have hypoxemia. Oxygen therapy should be titrated based on the client's oxygen saturation levels to avoid suppressing the respiratory drive.
Choice B reason: The use of incentive spirometry is beneficial for clients with emphysema as it encourages deep breathing and helps prevent atelectasis. It is an appropriate intervention to include in the plan of care.
Choice C reason: Breathing exercises for clients with emphysema typically focus on prolonging the exhalation phase, not the inhalation phase, to improve airway clearance and reduce the work of breathing.
Choice D reason: Limiting fluid intake is not generally recommended for clients with emphysema unless there are specific contraindications. Adequate hydration can help thin secretions and improve mucus clearance.
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