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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Absence of impulsive behaviors is not a risk factor for becoming a perpetrator of child abuse. Impulsive behaviors can lead to unpredictable and potentially harmful actions, but their absence does not increase the risk of abusive behavior.
Choice B rationale:
Being involved in community activities is generally a positive factor and does not increase the risk of becoming a perpetrator of child abuse. It can provide a support network and positive role models, which can help prevent abusive behaviors.
Choice C rationale:
Low tolerance for frustration is a risk factor for becoming a perpetrator of child abuse. Frustration can lead to anger and potentially harmful actions, especially if the person does not have effective coping mechanisms.
Choice D rationale:
A submissive personality is not a risk factor for becoming a perpetrator of child abuse. While it may affect interpersonal relationships, it does not directly increase the risk of abusive behavior.
Correct Answer is B
Explanation
Choice A rationale:
While it’s important to understand the client’s situation, the immediate safety of the baby is the priority.
Choice B rationale:
This response is the priority as it assesses the immediate safety of the baby.
Choice C rationale:
While support is important, the immediate safety of the baby is the priority.
Choice D rationale:
While communication with the partner is important, the immediate safety of the baby is the priority.
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