A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

The client reports that the restraints are too tight.

The client has been in the restraints for 4hr.

The client is able to calmly follow commands.

The client can explain the reasons for their behavior.

Answer and Explanation

The Correct Answer is C

A. The client reports that the restraints are too tight: This indicates a need for adjustment of the restraints but does not necessarily indicate that the restraints should be discontinued altogether. The client's ability to follow commands and behave safely is a more critical factor in deciding whether to discontinue the restraints.
B. The client has been in the restraints for 4 hours: While prolonged use of restraints should be avoided due to the risk of complications such as skin breakdown and loss of mobility, the duration alone may not be the sole indicator for discontinuing restraints. The client's behavior and ability to follow commands are more important considerations.
C. The client is able to calmly follow commands: This is the most appropriate finding indicating that the restraints should be discontinued. Calmly following commands suggests that the client's behavior has improved and they are no longer a danger to themselves or others, making the restraints unnecessary.
D. The client can explain the reasons for their behavior: While understanding the reasons for the client's behavior is important for addressing underlying issues, it does not necessarily indicate that the client is no longer a risk to themselves or others. The ability to calmly follow commands is a more immediate concern when deciding whether to discontinue restraints.

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Correct Answer is B

Explanation

A. A bologna sandwich on rye bread: Rye bread contains gluten, which is harmful to individuals with celiac disease. Therefore, foods containing gluten, such as rye bread, should be avoided in the diet of a preschooler with celiac disease.
B. Corn tortilla with black beans: Corn tortillas and black beans are both gluten-free options and suitable for individuals with celiac disease. Corn tortillas are made from cornmeal, which does not contain gluten, making them a safe choice for individuals with celiac disease. Black beans are also naturally gluten-free and can provide essential nutrients like protein and fiber to the preschooler's diet.
C. Whole wheat pasta with shrimp: Whole wheat pasta contains gluten, which is not suitable for individuals with celiac disease. Therefore, whole wheat pasta should be avoided in the diet of a preschooler with celiac disease.
D. Low sodium vegetable soup with barley: Barley contains gluten and is not suitable for individuals with celiac disease. Therefore, foods containing barley, such as vegetable soup with barley, should be avoided in the diet of a preschooler with celiac disease.

A. "You should wear a snug-fitting bra continuously for 72 hours." B. "You should apply moist heat to your breasts four times per day." C. "You should limit your fluid intake to 1 liter per day." D. "You should manually express milk when engorgement occurs."

Correct Answer is A

Explanation

A. "You should wear a snug-fitting bra continuously for 72 hours": Wearing a snug-fitting bra continuously for 72 hours can help suppress lactation by providing support and reducing stimulation to the breasts. This can help prevent milk production and engorgement.
B. "You should apply moist heat to your breasts four times per day": Moist heat can stimulate milk production and should be avoided when trying to suppress lactation.
C. "You should limit your fluid intake to 1 liter per day": Adequate hydration is important for overall health, and limiting fluid intake to 1 liter per day is not advisable, especially postpartum when hydration needs may be higher.
D. "You should manually express milk when engorgement occurs": Manual expression of milk can stimulate milk production and should be avoided when attempting to suppress lactation. If engorgement occurs, cold compresses or ice packs can be used to reduce discomfort without stimulating milk production.

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A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

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