which of the following interventions should the nurse implement for a client with dementia who is at risk of falling
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ATI PN Comprehensive Predictor 2020

1. Which of the following interventions should the nurse implement for a client with dementia who is at risk of falling?

Correct answer: D

Rationale: The correct intervention for a client with dementia at risk of falling is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention helps in preventing falls by alerting the staff when the client tries to get out of bed. Keeping the bed in the lowest position (Choice A) may not prevent falls and could make it challenging for staff to provide care. Raising all four side rails (Choice B) can be a restraint and is not recommended as it may lead to entrapment or other risks. Assisting with ambulation every 2 hours (Choice C) may not be feasible or effective in preventing falls, as the client may attempt to get out of bed at any time.

2. A client with COPD is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps maintain airway patency by preventing the collapse of small airways during exhalation, improving breathing efficiency. Administering oxygen at 2 L/min via nasal cannula may be appropriate for some COPD patients but is not the priority intervention. Positioning the client in high Fowler's position may help improve breathing but is not as specific as pursed-lip breathing for COPD. Encouraging deep breathing and coughing may be beneficial in other respiratory conditions, but it is not the most effective intervention for COPD.

3. What is the most appropriate action for a healthcare provider to take when a patient is experiencing a seizure?

Correct answer: A

Rationale: During a seizure, the most appropriate action for a healthcare provider is to protect the patient's head. This helps prevent injury, especially considering the involuntary movements and potential thrashing associated with seizures. Restraint should be avoided as it can lead to further injury or distress for the patient. Inserting an airway is not recommended during an active seizure as the patient's airway may not be obstructed, and it could pose a risk of injury. Giving the patient water during a seizure is also not advisable as there is a risk of aspiration. Therefore, the priority is to ensure the patient's safety by protecting their head.

4. What are the early signs of hypoglycemia in a diabetic patient?

Correct answer: A

Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.

5. How should a healthcare professional assess a patient with a suspected infection?

Correct answer: A

Rationale: When assessing a patient with a suspected infection, it is crucial to monitor temperature and check for elevated white blood cells. Elevated temperature indicates a potential infection, and increased white blood cells are a sign of inflammation and the body's response to an infection. Monitoring blood pressure (choice B) and checking for fever (choice B) are not as specific indicators of infection as monitoring temperature and white blood cell count. Assessing changes in mental status and monitoring urine output (choice C) are important aspects of patient assessment but may not directly indicate a suspected infection. Administering antibiotics (choice D) should only be done after a confirmed diagnosis of a bacterial infection, as unnecessary antibiotic use can lead to antibiotic resistance and other adverse effects.

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