A nurse is planning care for an older adult client who has a history of dementia and is admitted following surgical repair of a hip fracture. Which of the following actions should the nurse plan to take?
Encourage frequent visits from friends.
Keep the over-the-bed light on.
Apply restraints to the upper extremities.
Play serene, soothing music.
The Correct Answer is D
A. Encourage frequent visits from friends: While social interaction can be beneficial, it’s important to consider the individual’s needs and preferences. Overstimulation from too many visitors can cause anxiety or confusion, which can worsen cognitive symptoms.
B. Keep the over-the-bed light on: This may be helpful in preventing falls or confusion at night. However, it’s essential to avoid excessive lighting as it can disrupt the circadian rhythm, potentially leading to sleep disturbances. A dim nightlight is more appropriate.
C. Apply restraints to the upper extremities: Restraints should not be used as a first-line approach. They can increase confusion, anxiety, and the risk of injury. Non-restrictive interventions, such as proper positioning and a calm environment, should be prioritized.
D. Play serene, soothing music: Soothing music can be a helpful intervention to reduce anxiety, agitation, and confusion in clients with dementia. Music has been shown to have a calming effect, which can help the client feel more relaxed and at ease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Increased sexual desire: Menopause typically leads to a decrease in sexual desire due to the reduction in estrogen levels. This hormonal shift can cause physical changes such as vaginal dryness and discomfort, further impacting libido.
B. Decreased bone density: Estrogen plays a crucial role in maintaining bone density, and its decline during menopause accelerates bone resorption. This results in decreased bone mass and an increased risk of osteoporosis and fractures.
C. Decreased sweating: Hot flashes, characterized by sudden increases in body temperature followed by sweating, are a hallmark symptom of menopause. These occur due to changes in the hypothalamus's regulation of temperature, often triggered by fluctuating estrogen levels.
D. Increased vaginal secretions: As estrogen levels decrease during menopause, vaginal tissues become thinner and less lubricated. This often results in vaginal dryness and discomfort, which can cause pain during intercourse and increase the risk of infections.
Correct Answer is A
Explanation
A. Lie down when taking the medication: Sublingual nitroglycerin causes vasodilation, which can lower blood pressure and potentially cause dizziness or fainting. The client should lie down or sit in a comfortable position to minimize the risk of falls or injury.
B. Chew the medication thoroughly: Sublingual nitroglycerin should be placed under the tongue and allowed to dissolve completely, not chewed. Chewing may affect the absorption and effectiveness of the medication.
C. Store the medication in the refrigerator: Sublingual nitroglycerin should be stored at room temperature, away from moisture and heat, not in the refrigerator. Cold storage could reduce the medication's effectiveness.
D. Check the expiration date on the medication every 6 months: While it is important to check the expiration date, every 6 months is not sufficient. The client should check the expiration date more frequently (e.g., every 3 months) and replace the medication if expired to ensure it is effective when needed.
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