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 ["A","B","C"]
Explanation
Choice A rationale: Taking iron supplements on an empty stomach increases their absorption. Food can interfere with the absorption of iron, so taking it 1 hour before meals or 2 hours after meals is recommended to maximize the amount of iron absorbed by the body. This is important for effectively managing iron deficiency anemia.
Choice B rationale: Increasing dietary fiber can help manage potential side effects of iron supplementation, such as constipation. Fiber-rich foods can aid in maintaining regular bowel movements and prevent gastrointestinal discomfort, which is a common issue with iron supplements.
Choice C rationale: Vitamin C enhances the absorption of non-heme iron, which is the type of iron found in supplements and plant-based foods. Taking iron supplements with a source of vitamin C, such as orange juice, can significantly increase the amount of iron absorbed by the body, improving the treatment of iron deficiency anemia.
Choice D rationale: Taking an antacid within 30 minutes after iron supplementation is not recommended, as antacids can decrease the absorption of iron by raising the pH level in the stomach. This can reduce the effectiveness of the iron supplement.
Choice E rationale: Milk and dairy products contain calcium, which can inhibit the absorption of iron. Increasing the intake of milk and dairy products should be avoided around the time of taking iron supplements to ensure maximum absorption of iron.
Correct Answer is B
Explanation
Choice B rationale
Dimming the lighting in the client's room helps reduce photophobia and headaches, which are common symptoms in viral meningitis.
Choice A rationale
Monitoring temperature every 6 hours is not as frequent as needed. Frequent monitoring is crucial due to the risk of rapid changes in condition.
Choice C rationale
Contact precautions are not necessary for viral meningitis, as it is not as contagious as bacterial meningitis. Standard precautions are generally sufficient.
Choice D rationale
Measuring intake and output every 8 hours is standard, but it is not specific to the needs of a viral meningitis patient like controlling environmental stimuli.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.