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:

A motor-vehicle crash is an adventitious crisis, not a maturational one.

Choice B rationale:

A child leaving for college is a normal developmental milestone that can cause stress.

Choice C rationale:

Loss of a job is a situational crisis, not a maturational one.

Choice D rationale:

Divorce is a situational crisis, not a maturational one.

A. Bradycardia B. Diarrhea. C. Hypokinesis. D. Meiosis.

Correct Answer is B

Explanation

Choice A rationale:

This statement is incorrect. Opioid withdrawal typically results in tachycardia, not bradycardia.

Choice B rationale:

This statement is correct. Diarrhea is a common symptom of opioid withdrawal.

Choice C rationale:

This statement is incorrect. Opioid withdrawal often results in restlessness and agitation, not hypokinesis.

Choice D rationale:

This statement is incorrect. Opioid withdrawal typically results in dilated pupils, not meiosis.

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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?.