a nurse is caring for a client who has dementia and is at risk of falling what is the best intervention to prevent injury a nurse is caring for a client who has dementia and is at risk of falling what is the best intervention to prevent injury
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Nursing Elites

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1. A client with dementia is at risk of falling. What is the best intervention to prevent injury?

Correct answer: B

Rationale: Using a bed exit alarm is the best intervention to prevent injury in a client with dementia at risk of falling. This device alerts staff when the client attempts to leave the bed, allowing for timely assistance and reducing the risk of falls. Placing the client in a room close to the nurses' station may help with supervision but does not provide immediate alerts like a bed exit alarm. Encouraging family members to stay with the client at all times may not be feasible, and raising all four side rails can lead to restraint issues and is not recommended unless necessary for the client's safety.

2. A nurse is teaching a client about the use of nitrofurantoin. Which of the following should be included?

Correct answer: A

Rationale: The correct answer is A. Nitrofurantoin can cause a harmless brown discoloration of urine. Choice B is also correct as it should be taken with food to enhance absorption. Choice C is incorrect as nitrofurantoin does have side effects, such as gastrointestinal disturbances. Choice D is incorrect as nitrofurantoin is not recommended during the last month of pregnancy due to potential risks to the fetus.

3. A nurse is caring for a client with a recent diagnosis of myasthenia gravis. Which of the following medications should the nurse expect to administer?

Correct answer: B

Rationale: Pyridostigmine is the drug of choice for treating myasthenia gravis because it enhances communication between nerves and muscles by inhibiting acetylcholinesterase. Methotrexate (choice A) is not indicated for myasthenia gravis but is used in conditions like rheumatoid arthritis. Baclofen (choice C) is a muscle relaxant used for conditions like spasticity. Atropine (choice D) is not typically used in myasthenia gravis as it can worsen muscle weakness.

4. Which condition may benefit from branched chain amino acids (leucine, isoleucine, and valine)?

Correct answer: A

Rationale: Branched chain amino acids, such as leucine, isoleucine, and valine, are essential in preventing muscle breakdown. Therefore, they may be particularly important for a patient with cancer-related malnutrition, where maintaining muscle mass is crucial. Marasmus is a severe form of malnutrition characterized by energy deficiency, not specifically related to cancer. Cardiovascular disease and severe depression do not have a direct correlation with the need for branched chain amino acids to prevent muscle breakdown.

5. A nurse is reviewing the laboratory results for a client who has Cushing's disease. The nurse should expect the client to have an increase in which of the following laboratory values?

Correct answer: A

Rationale: The correct answer is A: Serum glucose level. In Cushing's disease, there is an excess production of cortisol, leading to hyperglycemia. This results in an increase in serum glucose levels. Choices B, C, and D are incorrect because Cushing's disease does not directly affect serum calcium levels, lymphocyte count, or serum potassium levels.

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