A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?
The client's hand is cool and pale
The client has full range of motion in her wrist
The client is attempting to remove the restraint.
The client has a capillary refill of less than 2 seconds.
The Correct Answer is A
A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "It will be a change for you, but a normal lifestyle is still possible. What concerns you the most?": This response acknowledges the patient's feelings while offering reassurance that life can still be fulfilling after surgery. It also invites the patient to express their concerns, allowing the nurse to address specific worries and provide tailored support.
B. "How has your husband reacted to the news?": While understanding the patient's support system is important, this response does not directly address the patient's expressed feelings of disbelief and may not be the most immediate concern for the patient at this moment.
C. "Don't worry. Many patients have had this same surgery and learn to manage very well.": While meant to offer reassurance, this response may come across as dismissive of the patient's feelings of disbelief and anxiety about the upcoming surgery.
D. "You sound like you are in disbelief. Why do you feel this way?": This response acknowledges the patient's expressed emotion but may come across as confrontational or probing, potentially making the patient feel defensive. It's important to provide support and reassurance while inviting the patient to share their concerns in a non-threatening manner.
Correct Answer is B
Explanation
A) Delayed gastric emptying: This condition refers to a slowdown in the movement of food from the stomach to the small intestine, often leading to symptoms like nausea, vomiting, bloating, and early satiety. It is not related to breath sounds and would not be detected through auscultation of the lungs.
B) Atelectasis: This condition involves the collapse or closure of lung tissue, resulting in reduced or absent gas exchange. It commonly occurs in patients who are immobile or on bedrest for extended periods, such as the client with a lacerated spleen. Decreased breath sounds in the lower lobes of the lungs are a typical finding in atelectasis, as the collapsed or partially collapsed alveoli do not allow air to move through them, leading to diminished or absent breath sounds in the affected areas.
C) An upper respiratory infection: This condition involves infections in the nose, throat, and airways and typically presents with symptoms like cough, nasal congestion, sore throat, and sometimes fever. It can affect breath sounds, but it more commonly causes wheezing, crackles, or rhonchi rather than isolated decreased breath sounds in the lower lobes.
D) Pulmonary edema: This condition is characterized by the accumulation of fluid in the lungs, often due to heart failure or acute lung injury. Auscultation findings typically include crackles or rales, particularly in the lower lung fields, but not necessarily decreased breath sounds unless there is a significant consolidation or fluid volume.
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