A nurse is caring for a client.

Exhibits

The nurse is collecting data from the client 12 hr. later. How should the nurse interpret the following findings?
For each potential finding, specify whether the finding is an indication of potential improvement or an indication of potential worsening condition.

Choice A Reason

Observing range of motion of client's extremities: It is crucial to monitor the range of motion of a client's extremities when they are in restraints. This helps in identifying any signs of impaired circulation, nerve damage, or muscle atrophy. Regular observation ensures that the restraints are not causing harm and that the client maintains as much mobility as possible. Documentation of these observations is essential for ongoing assessment and care planning.

Choice B Reason

Providing opportunities for nutrition and toileting: Clients in restraints still have basic needs that must be met, including nutrition and toileting. Ensuring that these needs are addressed helps in maintaining the client's dignity and preventing complications such as dehydration, malnutrition, and incontinence. Documenting these opportunities shows that the nurse is providing comprehensive care and addressing all aspects of the client's well-being.

Choice C Reason

Attempts at less restrictive interventions: Before applying restraints, it is important to try less restrictive interventions. This could include verbal de-escalation, offering a quiet environment, or providing comfort measures. Documenting these attempts is crucial as it demonstrates that the use of restraints was a last resort and that all other options were considered and tried. This documentation is important for legal and ethical reasons, ensuring that the client's rights are respected.

Choice D Reason

Observation of the client once per hour: Regular observation of a client in restraints is necessary to ensure their safety and well-being. Observing the client at least once per hour allows the nurse to monitor for any signs of distress, discomfort, or complications related to the restraints. This frequent monitoring helps in promptly addressing any issues that arise and ensures that the client is receiving appropriate care. Documentation of these observations provides a record of the client's condition and the care provided.

Choice E Reason

Names of staff members caring for the client: Documenting the names of staff members who are caring for the client is important for accountability and continuity of care. It ensures that there is a clear record of who was responsible for the client's care at any given time. This information is vital in case of any questions or concerns about the care provided and helps in coordinating care among the healthcare team.

Choice A Reason

Bradycardia: Bradycardia, or a slower than normal heart rate, is not typically associated with alcohol withdrawal. In fact, alcohol withdrawal is more commonly associated with tachycardia, which is an increased heart rate. This is due to the hyperactivity of the autonomic nervous system as the body reacts to the absence of alcohol. Symptoms like increased heart rate, sweating, and tremors are more indicative of alcohol withdrawal.

Choice B Reason

Double vision: Double vision, or diplopia, can be a symptom of alcohol withdrawal. This occurs due to the effects of alcohol on the central nervous system. When a person stops drinking, the brain and body go through a period of adjustment, which can lead to various neurological symptoms, including double vision. This is part of the broader spectrum of withdrawal symptoms that can include hallucinations and seizures in severe cases.

Choice C Reason

Drowsiness: Drowsiness is not a typical manifestation of alcohol withdrawal. Instead, individuals experiencing withdrawal are more likely to suffer from insomnia, restlessness, and agitation. The withdrawal process often leads to a hyperactive state rather than a sedative one, making drowsiness an unlikely symptom.