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
Explanation
Choice A rationale
Weighing the client before and after peritoneal dialysis helps assess fluid balance and ensure that the correct amount of fluid is removed during treatment. Monitoring weight changes is critical for evaluating the effectiveness of the dialysis.
Choice B rationale
Clean gloves are not sufficient for handling dialysate bags; sterile technique is required to prevent infection. Peritoneal dialysis involves a sterile procedure to reduce the risk of peritonitis.
Choice C rationale
The dialysate should be warmed to body temperature before infusion to prevent discomfort and vasoconstriction. Chilling the dialysate can cause abdominal cramping and reduce the effectiveness of the treatment.
Choice D rationale
Monitoring for diarrhea is not a standard part of peritoneal dialysis care. Peritonitis, not diarrhea, is a common complication of peritoneal dialysis, so monitoring for signs of infection is crucial.
Correct Answer is B
Explanation
Choice A rationale
Antifungal agents are not typically prescribed for acute glomerulonephritis. This condition is usually managed with other medications, such as antihypertensives and diuretics.
Choice B rationale
Decreasing sodium intake helps reduce edema by minimizing fluid retention. This dietary modification is a key part of managing acute glomerulonephritis.
Choice C rationale
Increasing daily fluid intake may worsen edema in patients with acute glomerulonephritis, as their kidneys are not functioning properly to excrete excess fluid.
Choice D rationale
While ambulation can be beneficial for overall health, it is not specifically recommended for managing acute glomerulonephritis with edema. The focus should be on reducing fluid retention.
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