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 C
Explanation
Choice A rationale
Avoiding eye contact to prevent confusion is incorrect. Eye contact is an important aspect of effective communication and helps to establish a connection with the client. Avoiding eye contact can make the client feel ignored or unimportant, which can hinder understanding and trust.
Choice B rationale
Speaking quickly to maintain the client’s attention is incorrect. Clients with cognitive impairment may have difficulty processing information quickly. Speaking slowly and clearly allows the client more time to understand and respond to the information being communicated.
Choice C rationale
Allowing the client extra time to respond is correct. Clients with cognitive impairment may need additional time to process information and formulate a response. Allowing extra time helps to ensure that the client fully understands the information and can respond appropriately.
Choice D rationale
Using complex sentences to stimulate cognitive function is incorrect. Simple and clear communication is more effective for clients with cognitive impairment. Complex sentences can be confusing and difficult for the client to understand, which can hinder effective communication.
Correct Answer is B
Explanation
Choice A rationale
A respiratory therapist is not typically required to assist a stroke client with dysphagia. Their expertise is more focused on respiratory issues rather than swallowing difficulties.
Choice B rationale
A speech therapist is the correct team member to assist a stroke client with dysphagia. Speech therapists specialize in diagnosing and treating swallowing disorders, which are common in stroke patients.
Choice C rationale
A physical therapist focuses on improving a client’s physical mobility and strength. While they play a crucial role in stroke rehabilitation, they are not specifically trained to address dysphagia.
Choice D rationale
A pharmacist’s role is to manage and dispense medications. They do not have the specialized training required to assist with dysphagia.
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