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 C
Explanation
Choice A rationale
Rotating the jejunostomy tube daily is not necessary and may cause unnecessary discomfort or complications.
Choice B rationale
Administering the feeding solution at a cold temperature can cause abdominal cramping and discomfort. It should be given at room temperature.
Choice C rationale
Elevating the head of the client's bed for 1 hour after feeding helps prevent aspiration, a serious complication of enteral feedings.
Choice D rationale
Flushing the tube with 90 mL of sterile water is excessive; the standard practice is to use 30-60 mL to clear the tube before and after feedings. .
Correct Answer is D
Explanation
Choice A rationale
Padded tongue blades are not recommended as they can cause injury or block the airway during a seizure.
Choice B rationale
A backboard is not necessary for a client with a seizure disorder. The focus should be on airway management and safety.
Choice C rationale
Wrist restraints are not appropriate and can cause harm during a seizure. The client should be kept safe and comfortable.
Choice D rationale
Suction equipment is essential to clear the client's airway of secretions or vomit during a seizure, helping to maintain a patent airway. .
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