A charge nurse is planning an in-service for a group of newly licensed nurses about the use of restraints. Which of the following information should the nurse include?
Record the client’s behavior every 15 min while in restraints.
Secure the restraint to the client’s bed rail using a slip knot.
Raising all four bedrails to keep a client in bed is not considered a restraint.
The nurse should assess a restrained client once every 2 hr.
The Correct Answer is A
Choice A reason: Recording the client’s behavior every 15 minutes while in restraints is correct because frequent documentation ensures safety, monitors the client’s physical and psychological status, and provides evidence that restraints are being used appropriately.
Choice B reason: Securing restraints to the bed rail is unsafe because bed rails move and can cause injury. Restraints should be secured to the bed frame using a quick-release knot, not a slip knot, to allow rapid removal in emergencies.
Choice C reason: Raising all four bedrails is considered a restraint if it restricts the client’s freedom of movement. This statement is incorrect because it misrepresents restraint guidelines.
Choice D reason: Assessing a restrained client only once every 2 hours is insufficient. Clients must be assessed at least every 15 minutes for safety, circulation, and comfort. Two-hour checks would not meet safety standards.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
This question assesses recent memory, which is a key component of cognition. Cognition includes orientation, attention, memory, language, and executive functioning. Asking about recent events helps the nurse evaluate the client’s ability to recall information and process experiences accurately.
Choice B reason:
This question assesses perception, specifically the presence of auditory hallucinations. Hallucinations are related to thought content and sensory perception rather than cognition, making this option incorrect.
Choice C reason:
This question assesses suicide risk and thought content. While critically important for safety, it does not evaluate cognitive functioning such as memory, attention, or orientation.
Choice D reason:
This question assesses coping mechanisms and stress management strategies. It provides insight into behavior and emotional regulation, not cognition.
Correct Answer is B
Explanation
Choice A reason: Lanugo is a fine, downy hair that develops on the body as a compensatory mechanism in clients with anorexia nervosa due to severe malnutrition and low body fat. It is not typically associated with bulimia nervosa, since bulimia involves recurrent binge eating followed by compensatory behaviors such as vomiting or laxative use, but does not usually result in the same degree of starvation seen in anorexia.
Choice B reason: Dental caries are expected in bulimia nervosa because repeated self-induced vomiting exposes teeth to gastric acid. This acid erodes enamel, leading to tooth decay, sensitivity, and caries. This is a hallmark physical finding in bulimia and directly reflects the purging behavior characteristic of the disorder.
Choice C reason: Cold extremities are more commonly associated with anorexia nervosa due to severe malnutrition, hypothermia, and poor circulation from low body fat. Clients with bulimia nervosa may have normal weight or even be overweight, so cold extremities are not a typical finding.
Choice D reason: Amenorrhea is more characteristic of anorexia nervosa due to extreme caloric restriction and low body fat, which disrupts hormonal regulation of the menstrual cycle. While menstrual irregularities can occur in bulimia nervosa, amenorrhea is not a defining or expected finding.
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