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 C

Explanation

A. Herbal medicine: While herbal medicine may offer some benefits for relaxation or symptom management, it is not recommended immediately before surgery. Some herbs can interact with anesthesia or medications, and their effects are not always well understood.

B. Magnet therapy: Magnet therapy is a complementary therapy often used for pain management or to promote healing, but there is limited evidence to support its effectiveness for acute anxiety.

C. Guided imagery: Guided imagery helps reduce anxiety and promote relaxation. It involves imagining a calm and peaceful setting, which can help distract the mind and reduce pre-surgical stress. This method is safe and effective for managing anxiety.

D. Acupuncture: While acupuncture may be helpful for managing pain and stress, it requires specific knowledge and skill to perform. Acupuncture should not be performed immediately before surgery unless administered by a trained practitioner.

A. Prop the feet up. B. Apply an abduction pillow to the legs. C. Use a trochanter roll. D. Use foot splints.

Correct Answer is D

Explanation

A. Prop the feet up: Proping the feet up may not be effective in preventing plantar flexion contractures, as it does not provide sustained support to keep the feet in a neutral position. Plantar flexion can still occur with this position.

B. Apply an abduction pillow to the legs: An abduction pillow is used to keep the hips in a neutral position, not to prevent plantar flexion contractures. It is useful for preventing hip contractures but not specifically for the feet.

C. Use a trochanter roll: A trochanter roll helps prevent external rotation of the hip joint, not plantar flexion of the feet. It is used for positioning to prevent hip complications, but it does not address foot position or contracture prevention.

D. Use foot splints: Foot splints are designed to keep the feet in a neutral or dorsiflexed position, preventing the toes from pointing downward (plantar flexion). This is the most effective intervention to prevent plantar flexion contractures in an immobile client.

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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?

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Naxlex Comprehensive Predictor Exams

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