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 D
Explanation
A. Fear
May be present, but persistent withdrawal is more characteristic of depression.
B. Stubbornness
Labeling the behavior as stubborn overlooks underlying psychological concerns.
C. Exhaustion
Fatigue may contribute, but alone does not fully explain the behavioral pattern.
D. Depression
Social withdrawal, appetite changes, and lack of interest are common signs of depression in older adults.
Correct Answer is C
Explanation
A. Constipation
Not part of SPICES. While bowel patterns are important, they are not included in this acronym.
B. Caregiver
SPICES is a patient-centered assessment tool, not focused on the caregiver.
C. Confusion
SPICES stands for: Sleep disorders, Problems with eating or feeding, Incontinence, Confusion, Evidence of falls, Skin breakdown.
D. Continence
"I" in SPICES stands for Incontinence, not "C".
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