A nurse is reinforcing teaching with the caregiver of a client who has Alzheimer's disease.
The caregiver reports that the client awakens at night and wanders.
Which of the following strategies should the nurse suggest?.
Use light restraints while the client is in bed.
Place a lock at the top of doors leading outside.
Encourage the client to nap during the day.
Administer an antianxiety medication before bedtime.
The Correct Answer is B
Choice A rationale:
Using restraints can lead to injury and is generally a last resort.
Choice B rationale:
Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
Choice C rationale:
Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
Choice D rationale:
While medication can be helpful, non-pharmacological interventions should be tried first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Obtaining a prescription for haloperidol is not the first intervention the nurse should implement. Medication should be considered only after non-pharmacological interventions have been attempted.
Choice B rationale:
Taking the client to the seclusion room is not the first intervention the nurse should implement. Seclusion should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
Choice C rationale:
Verbally de-escalating the client is the first intervention the nurse should implement. This involves using calm, clear communication to help the client regain control of their emotions.
Choice D rationale:
Placing the client in restraints is not the first intervention the nurse should implement. Restraints should be used only as a last resort when all other interventions have failed and the client is a danger to themselves or others.
Correct Answer is C
Explanation
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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