A nurse is caring for a client who is cognitively impaired and repeatedly pulls on his NG tube.
Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)
Provide diversionary activities for the client.
Assist the client with toileting at frequent intervals.
Involve the family in the client’s care.
Explain to the client that he will be restrained if he does not stop pulling on his NG tube.
Use an electronic bed alarm device.
Correct Answer : A,B,C,E
Choice A rationale
Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.
Choice B rationale
Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.
Choice C rationale
Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.
Choice E rationale
Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Administering diphenhydramine with food does not specifically address the adverse effect of dry mouth. While taking the medication with food can help reduce gastrointestinal side effects, it does not alleviate dry mouth.
Choice B rationale
Chewing on sugarless gum or sucking on hard candies can help stimulate saliva production and alleviate dry mouth. This is an effective and simple measure to manage the adverse effect of dry mouth associated with diphenhydramine.
Choice C rationale
Placing a humidifier at the bedside can help maintain moisture in the air, but it is not the most effective measure for managing dry mouth. Chewing gum or sucking on candies directly stimulates saliva production, providing more immediate relief.
Choice D rationale
Discontinuing the medication and notifying the provider is not necessary for managing dry mouth. Dry mouth is a common and manageable side effect of diphenhydramine. Simple measures like chewing gum or sucking on candies are usually sufficient to alleviate this symptom
Correct Answer is A
Explanation
Choice A rationale
Silvery, white scales are a characteristic finding in psoriasis. Psoriasis is a chronic autoimmune condition that causes rapid skin cell turnover, leading to the buildup of scales and red patches on the skin.
Choice B rationale
Intense pain is not typically associated with psoriasis. While psoriasis can cause discomfort and itching, it is not usually described as intensely painful.
Choice C rationale
Unilateral lesions are not characteristic of psoriasis. Psoriasis typically presents with symmetrical lesions on both sides of the body.
Choice D rationale
Serous drainage is not a common finding in psoriasis. Psoriasis lesions are usually dry and scaly rather than exudative. .
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