A nurse has placed a patient in restraints and obtained doctor's orders for the restraint.
Which action is appropriate for the nurse to conduct for a patient in restraints?

Choice A rationale:

The incident report is not a format for an audiotape report. Incident reports are written records used to document details of an unexpected event or accident, such as a patient fall, to analyze the causes and implement corrective measures.

Choice B rationale:

Incident reports are not primarily used as a basis for evaluating staff members and pay raises. They focus on patient safety and quality improvement, not employee performance evaluations.

Choice C rationale:

The primary purpose of an incident report is to identify risks and corrective measures. Incident reports are essential tools in healthcare facilities to track and analyze adverse events, identify patterns, and implement preventive measures to enhance patient safety. By documenting incidents and analyzing the data, healthcare organizations can identify potential risks and develop strategies to prevent similar occurrences in the future.

Choice D rationale:

While incident reports may be used as a basis for disciplinary actions in some cases, their main purpose is to improve patient safety. Disciplinary actions are taken after a thorough analysis of the incident report, which identifies areas for improvement and preventive measures.

Choice C rationale:

When a patient has been bedridden for an extended period, such as two weeks, the nurse expects to find atrophy of leg muscles due to immobility. Lack of physical activity leads to muscle wasting, which can result in decreased muscle mass and strength. This condition is reversible with proper rehabilitation and exercise.

Choice A rationale:

Decreased respiratory rate due to stronger lungs is not a typical effect of immobility. Immobility can lead to decreased lung expansion and increased risk of respiratory complications, such as pneumonia.

Choice B rationale:

Increased urinary output due to enhanced bladder muscle tone is not a direct effect of immobility. Immobility can affect urinary elimination, but it is more likely to cause urinary retention due to decreased mobility and inability to reach the bathroom independently.

Choice D rationale:

Frequent bowel movements due to increased peristalsis are not expected with immobility. Immobility often leads to slowed peristalsis, which can result in constipation rather than frequent bowel movements.