A nurse working the night shift is caring for an older adult client who has dementia and is at risk for falls.Which of the following actions should the nurse take?
Leave the television on in the client's room.
Apply a motion sensor mat to the client's bed.
Raise all four side rails while the client is in bed.
Move the overbed table away from the bed.
The Correct Answer is B
Choice A rationale
Leaving the television on in the client's room can cause confusion and agitation in clients with dementia, leading to an increased risk of falls.
Choice B rationale
Applying a motion sensor mat to the client's bed is an effective way to alert staff if the client attempts to get out of bed, thereby reducing the risk of falls.
Choice C rationale
Raising all four side rails can be considered a form of restraint and can increase the risk of injury if the client attempts to climb over them.
Choice D rationale
Moving the overbed table away from the bed removes a potential source of support for the client when they attempt to get up, increasing the risk of falls. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Performing breast exams on the first day of the menstrual cycle is not recommended because hormonal fluctuations can affect breast tissue.
Choice B rationale
Breast self-examinations should be performed monthly, not every other month, to detect any changes in breast tissue.
Choice C rationale
Skin dimpling on the breast can be a sign of breast cancer and should not be considered common. It requires medical evaluation.
Choice D rationale
It is normal for one breast to be slightly larger than the other, and this variation is common among women.
Correct Answer is C
Explanation
Choice A rationale
Cabbage is low in potassium, making it a suitable food for clients who need to avoid high-potassium foods. It contains approximately 150 mg of potassium per cup, which is relatively low compared to other vegetables.
Choice B rationale
Watermelon is a fruit with moderate potassium content, containing about 170 mg of potassium per cup. While not extremely high, it is not the best choice for someone seeking to increase potassium intake significantly.
Choice C rationale
A medium potato is high in potassium, with about 900 mg of potassium. Potatoes are an excellent source of potassium, which is essential for maintaining proper muscle and nerve function.
Choice D rationale
An apple is low in potassium, containing around 150 mg per small apple. It is a good option for clients who need to limit their potassium intake, but not for those looking to increase it. .
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