A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

Move the client to a double room.

Use a bed alarm.

Encourage participation in activities that provide excessive stimulation.

Use chemical restraints at bedtime.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is D

Explanation

Choice A reason: A client with diabetes mellitus presenting with acute ketoacidosis does not necessarily require a private room unless there are other infection control concerns. Diabetic ketoacidosis (DKA) is a serious complication of diabetes that occurs when the body produces high levels of blood acids called ketones. It is a medical emergency that requires treatment in a hospital, but it is not contagious.

Choice B reason: An older adult client admitted with aspiration pneumonia would not typically require a private room solely based on this condition. Aspiration pneumonia is caused by inhaling food, stomach acid, or saliva into the lungs. It can lead to a bacterial infection, which may or may not be contagious depending on the causative organism.

Choice C reason: A client with a compound fracture of the right femur would not require a private room based on the diagnosis alone. A compound fracture, also known as an open fracture, is a fracture in which there is an open wound or break in the skin near the site of the broken bone. While it requires immediate medical attention to prevent infection, it is not a condition that necessitates isolation.

Choice D reason: A client who reports having fever, night sweats, and cough for 2 days may require a private room due to the possibility of an infectious disease that could be transmitted to others, such as tuberculosis (TB). These symptoms are concerning for TB, which is an airborne infectious disease and would require airborne precautions, including a private room with negative pressure ventilation.

A. Thyroidectomy B. Internal fixation of a fractured hip C. Repair of a torn rotator cuff D. Tympanoplasty

Correct Answer is B

Explanation

Choice A reason: Thyroidectomy is a surgical procedure that involves the removal of all or part of the thyroid gland. While there are risks associated with any surgery, thyroidectomy is not typically associated with fat embolism syndrome (FES). FES is more commonly linked to orthopedic procedures and trauma, particularly those involving long bones.

Choice B reason: Internal fixation of a fractured hip is a procedure that carries a risk for developing FES. FES is a serious and potentially life-threatening condition that occurs when fat globules enter the bloodstream and lodge within the blood vessels of the lungs or other organs. Hip fractures, especially those involving the long bones, can result in the release of fat globules into the bloodstream during the surgical repair process. Early surgical fixation is thought to reduce the risk of FES.

Choice C reason: Repair of a torn rotator cuff involves the shoulder joint and, while it is a significant surgical procedure, it is not typically associated with a high risk of FES. The rotator cuff is composed of muscles and tendons, and its repair does not usually involve manipulation of the long bones where fat embolism is more likely to occur.

Choice D reason: Tympanoplasty is a surgical procedure to repair a hole in the eardrum. It is an otologic procedure that does not involve the long bones or orthopedic manipulation. Therefore, it is not associated with a risk of developing FES.

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A nurse on a medical-surgical unit is planning care for a client who has dementia and a history of wandering. Which of the following actions should the nurse plan to implement?

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Naxlex Comprehensive Predictor Exams

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