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"]
Explanation
Choice A rationale: A BRCA1 mutation significantly increases the risk of breast cancer. BRCA1 and BRCA2 genes are involved in the repair of DNA damage, and mutations in these genes impair this function, leading to an increased likelihood of developing breast cancer. Women with a BRCA1 mutation have a substantially higher lifetime risk of breast cancer compared to the general population.
Choice B rationale: Race can be a risk factor for breast cancer, as certain racial and ethnic groups have differing incidences of the disease. Native American women, while having a lower overall risk compared to some other groups, may still have unique risk factors that contribute to their likelihood of developing breast cancer. Additionally, healthcare access and cultural factors can influence outcomes.
Choice C rationale: Having the first pregnancy at age 25 is associated with a lower risk of breast cancer compared to women who have their first pregnancy at a later age. Early full-term pregnancies are generally considered protective against breast cancer because they lead to differentiation of breast cells, which may reduce susceptibility to cancerous changes.
Choice D rationale: The biopsy result showing fibroadenoma, a benign breast tumor, does not itself increase the risk of breast cancer. Fibroadenomas are non-cancerous and are common among younger women. While they may require monitoring, they do not indicate a higher risk of malignancy.
Correct Answer is C
Explanation
Choice A rationale
Administering a broad-spectrum antibiotic is not appropriate for tinea corporis, which is a fungal infection. Antifungal medications are needed.
Choice B rationale
Isolating the client for 24 hours after lesions appear is not necessary, as tinea corporis is not a severe infection requiring isolation.
Choice C rationale
Avoiding direct contact is essential to prevent the spread of the fungal infection.
Choice D rationale
Placing the client on airborne precautions is not needed for tinea corporis, as it is not an airborne infection.
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