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.

Answer and Explanation

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. .

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Correct Answer is B

Explanation

Choice A rationale

Applying heat to a sprained ankle can increase swelling and should be avoided. Ice should be used instead to reduce swelling.

Choice B rationale

Wrapping the affected ankle with an elastic bandage helps to provide support, reduce swelling, and immobilize the joint.

Choice C rationale

Dangling the affected ankle can cause further injury and increase swelling. The ankle should be elevated to reduce swelling.

Choice D rationale

Bearing full weight on a sprained ankle can exacerbate the injury. The client should avoid putting weight on the ankle until it has healed sufficiently.

A. Padded tongue blades. B. Backboard. C. Wrist restraints. D. Suction equipment.

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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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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