A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

Obtain a prescription for restraints from the provider.

Document the indications for using wrist restraints.

Explain the procedure to the client and their family.

Attempt less restrictive alternatives.

Answer and Explanation

The Correct Answer is D

A.   While a prescription may be necessary, attempting less restrictive alternatives should be the first action.
B.   Documentation is important but should not precede attempting less restrictive alternatives.
C.   Education about the use of restraints is important but should follow attempts at less restrictive alternatives.
D.   The nurse should exhaust all possible alternatives to restraints before considering their use, in line with the principle of least restrictive intervention.

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Correct Answer is C

Explanation

A. This response is associated with cranial nerve II, the optic nerve.

B. Tongue position is associated with cranial nerve XII, the hypoglossal nerve.

C. A symmetrical smile is indicative of cranial nerve VII, the facial nerve.

D. This action is associated with cranial nerve XI, the accessory nerve.

A. Tell the client about the benefits of the surgery. B. Inform the client that it is too late to stop the surgery. C. Let the client know that their surgeon will be notified of their decision. D. Reassure the client that it is expected to be nervous before surgery.

Correct Answer is C

Explanation

A. While educating the client about the benefits of surgery is important, it is not appropriate to dismiss the client's concerns in this situation.

B. It is important to respect the client's autonomy and decision-making process. If the client expresses a desire to reconsider the surgery, their wishes should be respected.
C. The nurse should respect the client's decision and communicate their wishes to the surgical team for further discussion and decision-making.
D. While reassurance is important, it should be provided in a way that acknowledges and respects the client's concerns and decisions.

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A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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