The nurse is caring for a client who is confused and wanders. ...

[strangeaffliction]

The nurse is caring for a client who is confused and wanders. Which alternative to a restraint can the nurse use for this client?
 
  1. Assign this client to the farthest room from the nurses' station.
  2. Place a rocking chair in the client's room.
  3. Pull up all of the side rails on the bed.
  4. Wedge pillows against the side rails on the bed.

Question 2

An older client diagnosed with Alzheimer's disease continually tries to get out of bed at night. Which safety measure should the nurse consider using with this client?
 
  1. Explain all procedures and treatments.
  2. Place a bed safety monitoring device on the bed.
  3. Orient the client to surroundings.
  4. Use relaxation techniques.

[britb2u]

Answer to Question 1

Correct Answer: 2
Rationale 1: Assigning the client to the farthest room from the nurses' station would be an unsafe move for the client; closer would be safer than farther.
Rationale 2: Placing a rocking chair in the client's room will help her to expend some of her energy so that she will be less inclined to walk and wander.
Rationale 3: Pulling up all of the side rails is a restraint, so that action would not be an alternative.
Rationale 4: Keeping pillows wedged against the side rails will not keep the client from wandering. She is not in the bed.

Answer to Question 2

Correct Answer: 2
Rationale 1: Explaining procedures would not be appropriate with this client.
Rationale 2: Alzheimer's disease causes impaired intellectual functioning, so a safety device that is weight sensitive would alert the nurse when the client is trying to get out of bed.
Rationale 3: Orienting to surroundings would not be appropriate with this client.
Rationale 4: Using relaxation techniques would not be appropriate with this client.