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 A
Explanation
A. Decreased blood flow to the liver: Aging reduces hepatic perfusion, impairing the liver’s ability to metabolize drugs, especially in patients with liver disease.
B. Increased body fat: This affects the distribution of fat-soluble drugs but not clearance.
C. Decreased serum albumin: This affects protein binding and distribution of certain drugs but not clearance directly.
D. Decreased body water: This influences water-soluble drug distribution, not drug clearance.
Correct Answer is C
Explanation
A. Wrinkles
Caused by loss of collagen and elasticity, not directly by oil loss.
B. Brown spots
Caused by sun exposure and aging, unrelated to skin oil content.
C. Itching
Loss of skin oils leads to dryness, which commonly causes pruritus (itching).
D. Infection
Infection may result from skin breaks, but is not a direct result of oil loss.
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