1. Which statement made by nursing assistive personnel (NAP) assigned to care for a patient with dementia requires the nurse to follow up?

1. "I encouraged his son and daughter-in-law to stay with him during visiting hours, if possible, even if they run out of things to talk about."
2. "He can't see his Foley because it's covered by his boxer shorts."
3. "I'll ask the patient every hour or so whether he needs to use the bathroom."
4. "He doesn't understand much of what anyone says to him today, so I didn't put in his hearing aids."

2. What would the nurse instruct nursing assistive personnel (NAP) to report when caring for a patient in a wrist restraint?

1. “Tell me if the patient’s pulse changes.”
2. “Tell me if the skin under the restraint becomes abraded or raw.”
3. “Let me know if you think she’s ready for them to come off.”
4. “Let me know if the patient needs anything for pain.”

3. To which patient might the nurse apply a physical restraint?

1. An 83-year-old patient with dementia and a history of wandering whose fall risk assessment indicates a high risk of falling
2. A 42-year-old critical care patient with a traumatic brain injury who has repeatedly tried to pull out her shunt
3. A 74-year-old patient confined to bed that is at risk of pressure ulcers
4. A 60-year-old patient with dementia who seemed increasingly confused shortly after having had restraints applied for 1 hour that morning

4. When caring for a patient with Alzheimer’s disease, why does the nurse cover the external urinary collection catheter?

1. To protect the bed from being soiled
2. To avoid offending visitors who would otherwise see the device
3. To reduce the patient’s access to the device
4. To keep the patient from trying to get out of bed alone

5. The nurse is discussing the risk of falling with the wife of a patient with cognitive impairment. What is the nurse’s best response when the patient's wife says, “I don’t like him being tied down in the bed?”

1. "I’m sure you don’t want him to fall again."
2. "Can you suggest an alternative?"
3. "What did you do to prevent him from falling when he was at home?"
4. "We will try all other alternatives before using physical restraints."

6. When a nursing assistive personnel (NAP) enters the room of a patient in a belt restraint, he finds the patient’s gown bunched around the patient’s chest and the patient asking for help. What would the NAP do?

1. Check the patient’s blood pressure and pulse before smoothing the gown
2. Untie the restraint and smooth the patient’s gown
3. Put on the call light for help
4. Ask the patient what specific help she would like

7. The nurse has one bed alarm available and can use it for any of the following patients, all of whom have dementia. Having an alarm is most important for which patient?

1. A patient who has refused most meals for the past week and whose weight has dropped by 10% in the past month
2. A patient who has become verbally combative with staff in recent weeks
3. A patient who was returned to the unit last week by staff in an adjacent assisted living facility
4. A patient whose abdominal feeding tube is covered with an abdominal binder

8. Which nursing action is the most therapeutic in response to a cognitively impaired patient who demands to know when his daughter is coming to visit?

1. Marking the date of the visit on the patient’s wall calendar
2. Evaluating the patient’s understanding of the concept of time and date
3. Telling the patient when his daughter will be visiting and ensuring that he verbalizes his understanding
4. Calling the daughter to suggest that she visit sooner than she had planned

9. The nurse wants to offer some diversional activity to a patient with dementia. The patient's family has told the nurse that he is a bit of a loner who enjoyed a 40-year career as an aircraft mechanic. The patient seems frustrated and bored. What is the best activity for the nurse to offer him?

1. Weekly pet therapy with a golden retriever
2. A jigsaw puzzle of an appropriate level of difficulty
3. A crossword puzzle book of an appropriate level of difficulty
4. Frequent card games with other patients

10. Why does the nurse instruct nursing assistive personnel (NAP) to remove the wrist restraint of a confused patient every 2 hours?

1. To try a less restrictive type of restraint if a more confining restraint has proved effective
2. To double-check the size by inserting two fingers between the wrist and the restraint
3. To check the skin integrity and range of motion of the wrist
4. To comply with Joint Commission standards