A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?
The restraint is attached to the side rails of the bed.
The restraint the strap is tied into a knot.
The nurse can insert two fingers under the restraint.
The skin under the restraint is cool and has changed color.
The Correct Answer is C
A. The restraint is attached to the side rails of the bed: Restraints should never be attached to the side rails because moving the rails could cause injury to the client. Restraints must be secured to a stationary part of the bed frame to prevent tightening, which could lead to impaired circulation or nerve damage if the bed position changes.
B. The restraint strap is tied into a knot: Tying the restraint strap into a knot is unsafe because knots are difficult to untie quickly in an emergency. Quick-release ties or slipknots are recommended to ensure the client can be released rapidly if needed, reducing the risk of injury or complications from prolonged restraint.
C. The nurse can insert two fingers under the restraint: Being able to insert two fingers under the restraint indicates that it is properly applied—not too tight to impair circulation, and not too loose to be ineffective. This ensures client safety by allowing adequate blood flow and reducing the risk of skin breakdown or nerve injury.
D. The skin under the restraint is cool and has changed color: Coolness and discoloration under a restraint are signs of impaired circulation and require immediate intervention. These findings are abnormal and suggest that the restraint is too tight, potentially leading to tissue ischemia, nerve damage, or pressure injuries if not promptly addressed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Medication: The medication, erythromycin, is clearly stated and appropriately spelled. There is no confusion about what drug the provider intended to prescribe, so there is no immediate need to clarify the medication name itself.
B. Route: The prescription does not specify the route of administration, which is essential for safe medication delivery. Erythromycin can be given orally or intravenously, and using the wrong route could lead to serious complications. Clarifying the route ensures proper technique and absorption.
C. Dosage: The dosage of 500 mg is within the standard therapeutic range for erythromycin, depending on the severity and type of infection. Since the dose appears appropriate, it does not require immediate clarification unless clinical concerns arise.
D. Time: Although "four times per day" is broad, it is generally understood as approximately every six hours. While more exact times can improve consistency, missing the route of administration is a more critical and urgent issue to clarify for client safety.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
- Report of menstrual cycle (absent for 3 months): The nurse’s notes state that the client has not had a menstrual period for three months. In hyperthyroidism, menstrual irregularities such as amenorrhea are common due to hormonal imbalance. This supports hyperthyroidism based on the client's current symptoms..
- Weight change (unplanned weight loss): The client reports experiencing unplanned weight loss over three months despite having a good appetite. This suggests an increased metabolic rate, which is consistent with hyperthyroidism. Unintentional weight loss despite normal eating is a key indicator.
- Skin condition (warm and moist): The client's skin is described as warm and moist during physical assessment. Hyperthyroidism causes increased blood flow and sweat gland activity, leading to this type of skin condition. It reflects the body's accelerated metabolic processes.
- Neck exam (goiter visualized): The nurse notes the presence of a visible goiter on neck examination. A goiter indicates thyroid gland enlargement, which occurs in hyperthyroidism due to overstimulation and overproduction of thyroid hormones. This is a major physical finding.
- Laboratory results (T3, T4, TSI ordered): The provider orders tests for T3, Free T4, and TSI to evaluate thyroid function. These specific labs are ordered when hyperthyroidism is suspected, particularly TSI which is associated with Graves’ disease. The decision to order them aligns with the findings.
- Eye appearance (exophthalmos noted): Exophthalmos, or outward bulging of the eyes, is noted by the nurse. This finding is strongly associated with hyperthyroidism, especially Graves' disease. It occurs due to inflammation and fluid buildup behind the eyes, worsening as thyroid dysfunction progresses.
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