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?

Use a bed alarm

Move client to a double room.

Use chemical restraints at bedtime.

Encourage participation in activities that provide excessive stimulation.

Answer and Explanation

The Correct Answer is A

A. Use a bed alarm: Bed alarms provide a safe method to alert staff when a client at risk for wandering attempts to leave the bed. This intervention promotes client safety without restricting freedom of movement, making it appropriate for dementia care.

B. Move client to a double room: Placing the client in a double room may increase confusion and agitation due to environmental overstimulation. It does not directly prevent wandering and could compromise safety.

C. Use chemical restraints at bedtime: Chemical restraints should be avoided unless absolutely necessary for safety and prescribed by a provider. They pose significant risks, including sedation, falls, and further cognitive decline, and are not a first-line intervention.

D. Encourage participation in activities that provide excessive stimulation: Excessive stimulation can increase agitation and the likelihood of wandering in clients with dementia. Activities should be calming, structured, and tailored to the client’s abilities to promote engagement without increasing risk.

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Correct Answer is B

Explanation

A. Use hot water when cleaning the client's skin.: Hot water can damage fragile skin and increase the risk of pressure injuries. The nurse should use lukewarm water and gentle cleansing techniques to protect skin integrity.

B. Provide the client with high-protein meals.: Adequate protein intake supports tissue repair and helps prevent progression of pressure injuries. Nutrition plays a critical role in maintaining skin health and promoting healing in clients at risk for skin breakdown.

C. Place the client in a supine position.: Continuous supine positioning increases pressure on the scapulae and other bony prominences, which can worsen skin breakdown. Frequent repositioning is necessary to relieve pressure and promote circulation.

D. Gently massage the reddened areas.: Massaging reddened areas can damage underlying tissue and worsen pressure injuries. The nurse should avoid direct pressure or massage on areas showing early signs of breakdown and instead use repositioning and protective devices.

A. "You can discard needles in an empty bleach bottle with a lid." B. "Remove the needle from the syringe before you place it in the trash," C. "Place your storage container in a recycle bin when it is full." D. "Secure the cap tightly over the needle before you discard it."

Correct Answer is A

Explanation

A. "You can discard needles in an empty bleach bottle with a lid.": Rigid, puncture-resistant containers such as bleach or detergent bottles are appropriate for home disposal of sharps. These containers reduce the risk of needle-stick injuries and can be sealed securely before disposal according to local guidelines.

B. "Remove the needle from the syringe before you place it in the trash.": Needles should never be removed or placed directly into household trash because this increases the risk of accidental injury to the client or sanitation workers. Leaving the needle attached and placing the entire device into a proper sharps container is the correct and safe method.

C. "Place your storage container in a recycle bin when it is full.": Sharps containers should never be placed in recycling because they pose a hazard and cannot be processed safely with recyclable materials. Full containers must be disposed of according to local regulations, often by returning them to designated medical waste facilities or drop-off sites.

D. "Secure the cap tightly over the needle before you discard it.": Recapping needles increases the risk of needle-stick injuries and is discouraged in all healthcare and home care settings. Used needles should be placed immediately into a puncture-resistant sharps container without recapping to minimize the chance of accidental exposure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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