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    Ati Rn Adult Medical Surgical 2023 Proctored Exam

    A nurse is planning care for a client who has dementia. Which of the following interventions should the nurse plan to include?

    Explanation & Rationale

    A. Clients with dementia often benefit from more frequent scheduled toileting, such as every 2 hours, to prevent incontinence and reduce agitation. Toileting every 4 hours may be insufficient and increase fall risk if the client attempts to toilet independently. B. Complete darkness can increase confusion, anxiety, and fall risk in clients with dementia. Low-level lighting or night-lights are recommended to help with orientation and safety. C. Keeping the bed in the lowest position reduces the risk of injury from falls, which is especially important for clients with dementia who may be confused or attempt to get out of bed without assistance. This is a key safety intervention. D. Sedatives increase the risk of falls, confusion, and respiratory depression in older adults with dementia. Nonpharmacologic interventions, such as maintaining routines and a calm environment, should be tried first.

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