The nurse is assisting with the care of an older adult client who has dementia. The client becomes confused and agitated at night and wanders into the hallway. Which of the following actions should the nurse take?
Turn out the lights in client's room at night.
Restrain the client during the nighttime hours
Provide continuous orientation to the client.
Place the client's mattress on the floor.
The Correct Answer is C
A. Turn out the lights in client's room at night
This can increase confusion or fear in clients with dementia, especially at night (sundowning). A nightlight is preferred to reduce disorientation.
B. Restrain the client during the nighttime hours
Physical restraints can increase agitation, injury, and are not recommended unless absolutely necessary. This is not a first-line intervention.
C. Provide continuous orientation to the client
Frequent reorientation helps reduce confusion. Strategies like using clocks, calendars, and familiar items are beneficial in managing sundowning and wandering.
D. Place the client’s mattress on the floor
This may help prevent injury from falls but does not address the cause of agitation or wandering. It’s a safety measure, not a therapeutic one.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Loss of brain neurons: This is a chronic, age-related process, not an acute change due to pneumonia.
B. Hypotension: While possible, it’s not the most common acute manifestation related to aging and infection.
C. Disorientation: Older adults often present with confusion or disorientation (delirium) as a sign of infection due to decreased physiologic reserves.
D. Sedation: Unless medications are involved, sedation isn’t an expected direct result of pneumonia or aging.
Correct Answer is A
Explanation
A. Speak clearly and distinctly while facing the patient: Presbycusis is age-related hearing loss, especially for high-pitched sounds; facing the patient allows for lip-reading and better auditory cues.
B. Place needed articles within easy reach: This is more relevant for fall prevention or physical limitations, not specifically hearing loss.
C. Orient the patient to time and place as needed: This intervention is for cognitive deficits such as dementia or delirium.
D. Announce your presence when entering the patient's room: While polite and helpful, it does not address the communication barrier caused by presbycusis as effectively as clear speech.
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