Mr. Olsen, age 75 years, lives in a nursing home and is diagnosed with mild dementia. Occasionally he attempts to get out of bed during the night and is a risk for falls. What nursing intervention should the practical nurse use to ensure his safety?
Place the bed in the lowest position at bedtime
Restrict fluid intake after 1800H
Apply a PRN restraint at HS
Ensure that all side rails are up at bedtime
The Correct Answer is A
Choice A reason: Placing the bed in the lowest position is a primary falls prevention strategy for patients with dementia. It minimizes the distance to the floor if the patient attempts to exit the bed unassisted, thereby reducing the impact and severity of potential injuries while maintaining the patient's dignity and autonomy.
Choice B reason: Restricting fluids after 1800H (6:00 PM) is generally discouraged as it can lead to dehydration and urinary tract infections in the elderly. While it might reduce nocturia, it does not address the underlying cognitive impairment causing the patient to wander or attempt to exit the bed during the night.
Choice C reason: The application of physical restraints, especially on a PRN (as needed) basis, is ethically and legally restricted. Restraints often increase agitation in patients with dementia and can lead to serious injuries or strangulation. They are considered a last resort and require specific, time-limited physician orders.
Choice D reason: Using four side rails is often classified as a form of physical restraint. For a patient with dementia, side rails can create a "caging" effect, leading the patient to attempt to climb over them. This significantly increases the risk of falling from a greater height, leading to more severe head or hip injuries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Patients with chronic schizophrenia often experience cognitive impairment and "concrete thinking," which limits their ability to process abstract concepts or complex instructions. Using clear, direct, and concrete language reduces the cognitive load and minimizes the potential for misunderstanding or overstimulation during the clinical interview.
Choice B reason: Open-ended and indirect questions require a high level of executive functioning and abstract reasoning to answer effectively. For a patient with schizophrenia, these types of questions can be overwhelming, leading to increased anxiety, tangentiality, or circumstantial speech patterns that hinder effective communication and data collection.
Choice C reason: While simple, "yes/no" questions are overly restrictive and do not encourage the patient to provide necessary clinical detail. They can lead to a "passive" interview style where the nurse misses important nuances about the patient’s symptoms, medication adherence, or general well-being in the outpatient setting.
Choice D reason: Therapeutic silence can be useful in general psychiatry, but for a patient with schizophrenia, prolonged silence may be interpreted as threatening, awkward, or confusing. It can also allow the patient to become lost in internal stimuli, such as auditory hallucinations, rather than staying grounded in the interview.
Correct Answer is D
Explanation
Choice A reason: Although 10 hours of sleep might seem positive, it may actually represent hypersomnia, which is a symptom of depression. Furthermore, the patient’s verbalization that they are a "failure" indicates that their cognitive distortions and low self-esteem remain unchanged, suggesting that the treatment has not yet effectively addressed the core depressive thoughts.
Choice B reason: Sleeping 7 hours is a normal physiological finding, but the patient remains "preoccupied" with thoughts of inadequacy. Effective treatment for depression should result in a reduction of ruminative negative thinking and an improvement in self-image. This documentation shows that the psychological symptoms of the depressive episode are still very much active.
Choice C reason: This choice indicates only marginal improvement. Sleeping only 5 hours with interruptions and requiring assistance for basic hygiene suggests significant lingering psychomotor retardation and sleep disturbance. A weight loss of 1 pound shows that the vegetative symptoms of depression, such as poor appetite, have not yet been resolved.
Choice D reason: This documentation shows improvement across multiple domains: sleep is stabilizing, the patient is actively participating in social activities (singing), and most importantly, they are demonstrating "future orientation" by anticipating a visit. Looking forward to future events is a significant clinical indicator that the pervasive hopelessness of depression is lifting.
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