A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?

Use a quick-release tie to restrain the client.

Renew the restraint prescription every 48 hr.

Attach the restraints to the side rail of the client's bed.

Maintain 1 fingerbreadth between the restraint and the client's skin.

Answer and Explanation

The Correct Answer is A

Choice A reason: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety. This method reduces the risk of injury to both the client and the healthcare team.

Choice B reason: Restraint prescriptions typically need to be renewed more frequently than every 48 hours, often within 24 hours. The exact duration depends on the facility's policy and regulatory guidelines. Regular assessment of the need for restraints and timely renewal of the prescription ensure that restraints are used appropriately and only as long as necessary.

Choice C reason: Attaching restraints to the side rail of the client's bed is unsafe and inappropriate. Restraints should be attached to a non-movable part of the bed frame to prevent the client from injuring themselves if the side rail is moved. Securing restraints to a stable part of the bed ensures better control and reduces the risk of harm.

Choice D reason: While maintaining some space between the restraint and the client's skin is important to prevent circulation issues, the guideline typically suggests maintaining two fingers' breadth between the restraint and the client's skin, not one. This ensures adequate circulation and reduces the risk of injury or skin breakdown.

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Correct Answer is A

Explanation

Choice A reason: A decrease in systolic blood pressure of 15 mm Hg after standing could indicate orthostatic hypotension, which is a known adverse effect of amitriptyline. Orthostatic hypotension can lead to dizziness, lightheadedness, and falls, posing a significant risk to the patient's safety. Reporting this finding to the provider is crucial for assessing the need for dosage adjustments or alternative treatments.

Choice B reason: Hypersalivation is not a common adverse effect of amitriptyline. While dry mouth is a more typical side effect, hypersalivation would be unusual and might indicate an unrelated issue or an interaction with another medication.

Choice C reason: Tinnitus, or ringing in the ears, is not typically associated with amitriptyline use. While it can occur as a side effect of some medications, it is not commonly linked to this particular drug.

Choice D reason: A weight loss of 3.6 kg (8 lb) over a 6-month period is not generally considered an adverse effect of amitriptyline. Weight changes can occur with many medications, but significant weight loss should be evaluated in the context of the patient's overall health and other medications they may be taking.

A. Serum creatinine. B. Thiamine level. C. Urinalysis. D. Erythrocyte sedimentation rate.

Correct Answer is B

Explanation

Choice A reason: Serum creatinine levels are commonly used to assess kidney function. While kidney function is important, it does not specifically evaluate nutritional status. Chronic alcohol use can impact multiple organs, but thiamine deficiency is a more direct concern related to nutritional status in these patients.

Choice B reason: Thiamine (vitamin B1) deficiency is a well-known complication of chronic alcohol use disorder. Alcohol interferes with the absorption and utilization of thiamine, leading to deficiencies that can cause severe neurological problems, such as Wernicke's encephalopathy and Korsakoff's syndrome. Monitoring thiamine levels is crucial in assessing and managing the nutritional status of clients with chronic alcohol use disorder.

Choice C reason: Urinalysis is a basic test that can provide information about kidney function and the presence of infections, among other things. However, it is not specifically useful in evaluating the nutritional status of a client with chronic alcohol use disorder. Nutritional deficiencies would not be directly assessed through a routine urinalysis.

Choice D reason: Erythrocyte sedimentation rate (ESR) is a non-specific marker of inflammation and is used to detect inflammatory conditions. While it can provide information on inflammatory processes, it does not directly assess nutritional status. The nutritional impact of chronic alcohol use disorder is more accurately evaluated by specific nutrient levels, such as thiamine.

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A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is taking amitriptyline. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?

Correct Answer is A

Explanation

A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?

Correct Answer is B

Explanation

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