A nurse is considering the use of restraints. The nurse should:
Ensure that the patient has been adequately monitored.
Proceed with the application of restraints.
Explore alternative interventions to address the patient’s behavior.
Obtain verbal consent from the patient’s family.
The Correct Answer is C
Choice A rationale
Ensuring that the patient has been adequately monitored is important, but it is not the first step when considering the use of restraints. The nurse should first explore alternative interventions.
Choice B rationale
Proceeding with the application of restraints without considering alternatives can lead to unnecessary use of restraints, which can cause physical and psychological harm to the patient.
Choice C rationale
Exploring alternative interventions to address the patient’s behavior is the first step. Restraints should only be used as a last resort when other interventions have failed.
Choice D rationale
Obtaining verbal consent from the patient’s family is important, but it is not the first step. The nurse should first explore alternative interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Calculating intake and output for the unit is a task that can be delegated to an LVN or UAP. It does not require the advanced clinical judgment and skills of an RN.
Choice B rationale
Inserting an NGT (nasogastric tube) for a client who is unable to eat is a task that can be performed by an LVN under the supervision of an RN. While it requires skill, it does not necessarily require the advanced clinical judgment of an RN.
Choice C rationale
Reinforcing teaching with a patient who is learning to walk with a quad cane can be done by an LVN or UAP. This task involves providing support and encouragement, but it does not require the advanced clinical judgment of an RN.
Choice D rationale
An unstable client complaining of feeling faint requires the advanced clinical judgment and skills of an RN. The RN is best equipped to assess the client’s condition, identify potential causes of instability, and implement appropriate interventions to stabilize the client.
Correct Answer is C
Explanation
Choice A rationale
Providing written handouts for reference can be helpful, but it is not the most effective strategy for fall prevention education among older adults. Interactive methods are generally more engaging and effective.
Choice B rationale
Using complex medical terminology to explain concepts is not effective for older adults. It can lead to confusion and misunderstanding, reducing the effectiveness of the education.
Choice C rationale
Using interactive demonstrations and group discussions is the most effective strategy for teaching fall prevention to older adults. These methods engage the audience, making the information more relatable and easier to understand.
Choice D rationale
Speaking quickly to maintain attention is not effective for older adults. It can lead to information being missed or misunderstood. Clear, slow, and interactive communication is more effective.
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