A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?.

Lower the window shade in the client's room.

Obtain a PRN prescription for a vest restraint.

Place the client in a room close to the nurses' station.

Request a consult with recreational therapy.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

Lowering the window shade in the client’s room does not directly contribute to fall prevention. It might even increase the risk if it makes the room darker and the client can’t see clearly.

Choice B rationale:

Using a vest restraint is not the best option. Restraints should be used as a last resort, and only if less restrictive interventions have been ineffective.

Choice C rationale:

Placing the client in a room close to the nurses’ station allows for more frequent observation and quicker response if the client needs assistance, reducing the risk of falls.

Choice D rationale:

While recreational therapy can be beneficial for clients with dementia, it does not directly address the issue of fall prevention.

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Correct Answer is B

Explanation

Choice A rationale:

Administering an antianxiety medication can help manage symptoms, but it’s not the first action a nurse should take.

Choice B rationale:

Calculating the client’s score on the Hamilton Rating Scale for Anxiety is the first step in assessing the severity of the client’s anxiety.

Choice C rationale:

Explaining the use of response prevention can be beneficial, but it’s not the first action the nurse should take.

Choice D rationale:

Discussing the benefits of relaxation exercises can help manage anxiety, but it’s not the first action the nurse should take.

A. Hypomagnesemia B. Hypokalemia. C. Muscle wasting. D. Lanugo.

Correct Answer is B

Explanation

Choice A rationale:

Hypomagnesemia is not a common finding in clients with bulimia nervosa.

Choice B rationale:

Hypokalemia is a common finding due to purging behaviors, such as self-induced vomiting or misuse of laxatives, which can lead to loss of potassium.

Choice C rationale:

Muscle wasting is more commonly associated with anorexia nervosa, not bulimia nervosa.

Choice D rationale:

Lanugo, or fine body hair, is also more commonly associated with anorexia nervosa, not bulimia nervosa.

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A nurse is caring for a client who has dementia and is experiencing an increased number of falls.
Which of the following actions should the nurse take?.