A nurse is observing a client who is in four-point restraints for violent and self-destructive behavior. Which of the following actions should the nurse take when using four-point restraints?

Assess the client every hr for circulation, possible injury, and readiness for discontinuation.

Check the client's peripheral pulses and skin integrity every 15 min.

Assist the client with passive range of motion exercises every 3 hr.

Attach the extremity restraint straps to the bed rails using a quick-release buckle.

Answer and Explanation

The Correct Answer is B

A. Assess the client every hr for circulation, possible injury, and readiness for discontinuation: While regular assessment is necessary, it should be done more frequently than every hour. A check every 15-30 minutes is recommended for safety.

B. Check the client's peripheral pulses and skin integrity every 15 min: Frequent assessments of circulation, skin integrity, and injury help prevent complications like tissue damage or nerve impairment.

C. Assist the client with passive range of motion exercises every 3 hr: Passive range of motion exercises should be done more frequently than every 3 hours to prevent stiffness and joint contractures.

D. Attach the extremity restraint straps to the bed rails using a quick-release buckle: Restraints should never be attached to bed rails, as this increases injury risk. Straps should be secured to a stationary part of the bed frame.

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Correct Answer is D

Explanation

A. Speech therapy referral: A speech therapy referral is appropriate for a client with dysphagia following a stroke. Speech therapists can assess the severity of swallowing difficulties and provide strategies to improve swallowing function. This is standard care.

B. Dietitian consult: A dietitian consult is essential to ensure proper nutritional intake and modify the client's diet for safe swallowing. A dietitian can help adjust the texture of foods and recommend alternatives to reduce the risk of aspiration.

C. Oral suction at the bedside: Oral suctioning is a precautionary measure for clients with dysphagia to clear any potential obstructions from the airway. It’s essential to have suction equipment available at the bedside in case of choking or aspiration.

D. Clear liquids: Clear liquids are not recommended for clients with dysphagia because they pose a higher risk for aspiration. Clear liquids can be difficult for individuals with swallowing difficulties to control and may lead to choking or aspiration pneumonia.

A. Bathe the client with soap and hot water. B. Massage bony prominences four times daily. C. Keep the head of the client's bed at 30° or less. D. Slide the client up in bed every 2 hr.

Correct Answer is C

Explanation

A. Bathe the client with soap and hot water: Hot water and soap can dry out the skin and worsen skin breakdown. The nurse should use lukewarm water and mild soap to prevent skin irritation, ensuring proper hydration and skin care.

B. Massage bony prominences four times daily: Massaging bony prominences can increase the risk of skin breakdown, as it may cause further tissue damage. Instead, the nurse should avoid massaging these areas and focus on preventive measures, such as repositioning.

C. Keep the head of the client's bed at 30° or less: Keeping the head of the bed at a 30° angle or less reduces pressure on the sacrum and other bony prominences. This position helps prevent further skin breakdown and promotes comfort for immobile clients.

D. Slide the client up in bed every 2 hr: Sliding the client up in bed increases friction, which can exacerbate skin breakdown. The nurse should use proper lifting techniques or assistive devices to reposition the client while minimizing friction and shearing forces.

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A nurse is observing a client who is in four-point restraints for violent and self-destructive behavior. Which of the following actions should the nurse take when using four-point restraints?

Nursing Test Bank

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