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 C

Explanation

Choice A reason: Informing the provider about the conversation might be necessary if there are concerns about confidentiality breaches, but it does not address the immediate issue of discussing private patient information in a public place. The charge nurse's first responsibility is to stop the inappropriate discussion and remind the staff nurse about the importance of maintaining patient privacy.

Choice B reason: While continuing the conversation in a private place is better than discussing it in a public hallway, the staff nurse should not be discussing private patient information unless it is necessary for the patient's care. The charge nurse should emphasize the importance of confidentiality and ensure that such conversations occur only when necessary and in appropriate settings.

Choice C reason: This response directly addresses the issue of discussing private patient information and reinforces the importance of maintaining confidentiality. By stating that it is an invasion of privacy to discuss the information, the charge nurse makes it clear that such conversations are inappropriate and should not occur.

Choice D reason: Telling the staff nurse not to use the client's name in public discussions misses the broader point about confidentiality. Even without using a name, discussing specific details about a patient's condition or admission can still breach their privacy. The charge nurse should emphasize the importance of not discussing patient information in public settings at all.

A. "As long as a person is not vomiting after eating they do not have bulimia nervosa." B. "People who have bulimia nervosa are at risk for developing diabetes mellitus." C. "Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight." D. "People who have bulimia nervosa eat an average amount of food on a daily basis."

Correct Answer is C

Explanation

Choice A reason: This statement is incorrect because individuals with bulimia nervosa can engage in other purging behaviors, such as the use of laxatives or excessive exercise, even if they do not vomit after eating. Therefore, the absence of vomiting does not rule out the diagnosis of bulimia nervosa.

Choice B reason: While individuals with bulimia nervosa may experience fluctuations in blood sugar levels due to their disordered eating behaviors, they are not specifically at a higher risk for developing diabetes mellitus compared to the general population. The primary health risks associated with bulimia nervosa are related to electrolyte imbalances, gastrointestinal issues, and cardiovascular complications.

Choice C reason: Bulimia nervosa can be difficult to detect because individuals with this disorder often maintain a weight that is within the average or ideal range. This can make it challenging for others to recognize the presence of an eating disorder, as the physical appearance may not immediately suggest a problem.

Choice D reason: This statement is incorrect because individuals with bulimia nervosa typically engage in binge eating episodes, during which they consume a large amount of food in a short period of time. These binge eating episodes are a key characteristic of the disorder and distinguish it from other eating disorders.

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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?

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