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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.

Answer and Explanation

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.

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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.

A. Reinforce teaching on the client's use of coping skills B. Encourage the client to use personal support systems. C. Assist with a client referral for social services. D. Identify if the client has thoughts of self-harm.

Correct Answer is D

Explanation

Choice A rationale:

Reinforcing teaching on the client’s use of coping skills is important, but it’s not the first action the nurse should take. The nurse must first ensure the client’s safety.

Choice B rationale:

Encouraging the client to use personal support systems is beneficial, but it’s not the first action. Safety is the priority.

Choice C rationale:

Assisting with a client referral for social services can be helpful, but it’s not the first action. The nurse must first assess for immediate safety risks.

Choice D rationale:

Identifying if the client has thoughts of self-harm is the first action the nurse should take. In a crisis situation, the client’s safety is the priority.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?.

Correct Answer is C

Explanation

A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?.

Correct Answer is D

Explanation

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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?.