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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A reason: Moving the client to a double room may not be effective in preventing wandering and could potentially lead to confusion or agitation if the client is not comfortable with the roommate or the new environment.

Choice B reason: Using a bed alarm is a non-invasive way to alert staff if the client attempts to leave the bed. This can help prevent wandering and ensure the safety of the client without restricting their movement unnecessarily.

Choice C reason: Encouraging participation in activities that provide excessive stimulation is not recommended for clients with dementia, as it can lead to increased confusion, agitation, and potentially exacerbate wandering behaviors.

Choice D reason: The use of chemical restraints, such as sedative medications, should be a last resort and only used when necessary to ensure the safety of the client or others. It is important to use the least restrictive measures first and to always consider the ethical implications of using chemical restraints.

A. Check the client's blood pressure every 8 hours. B. Monitor for hypokalemia as a manifestation of acute rejection. C. Assess urine output hourly. D. Administer opioids orally.

Correct Answer is C

Explanation

Choice A reason: Checking the client's blood pressure every 8 hours is important, but it is not as critical as monitoring urine output in the immediate postoperative period. Blood pressure should be monitored regularly, but changes in urine output can provide more immediate information about the new kidney's function.

Choice B reason: Monitoring for hypokalemia is important, as it can be a sign of acute rejection; however, hyperkalemia is more commonly associated with acute rejection due to the kidney's inability to excrete potassium. Therefore, while electrolyte monitoring is crucial, the focus is typically on hyperkalemia rather than hypokalemia.

Choice C reason: Assessing urine output hourly is essential for a client who has undergone a kidney transplant. Urine output is a direct indicator of the new kidney's function, and any significant decrease could indicate a complication such as acute rejection or obstruction.

Choice D reason: Administering opioids orally for pain management is part of postoperative care, but it is not the priority over monitoring urine output and kidney function.

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A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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