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 ["The correct answers are choices: Approach client slowly"," \r\n Maintain a low stimulation environment"," \r\n and Reorient client to person"," \r\n place"," \r\n and time frequently. Approach client slowly rationale: This is a therapeutic intervention for clients who are confused and agitated. It can help to reduce anxiety and promote trust. Alternate nursing staff daily rationale: This is not recommended as it can lead to confusion and anxiety in the client. Consistency in care providers can help to promote trust and understanding. Maintain a low stimulation environment rationale: This can help to reduce agitation and confusion in the client. A calm and quiet environment can promote relaxation and understanding. Reorient client to person"," \r\n place"," \r\n and time frequently rationale: This is a therapeutic intervention for clients who are confused. It can help to promote reality orientation and reduce confusion. Provide the client with limited information about the diagnosis rationale: This is not recommended as it can lead to confusion and anxiety in the client. Clients have the right to be fully informed about their diagnosis and treatment."]
No explanation
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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