A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.
Which of the following actions by the AP requires intervention by the nurse?

Using a quick-release tie to secure the restraint.

Tying the restraint to the bed frame.

Placing the restraint across the client's chest.

Applying the restraint over the client's gown.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.

Choice B rationale

Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.

Choice C rationale

Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.

Choice D rationale

Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.

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Correct Answer is D

Explanation

Choice A rationale

Verifying the bilirubin level of the tube contents is not a standard or reliable method for checking the placement of a feeding tube. Bilirubin is a bile pigment found in the liver and bile ducts, and its levels are not indicative of tube placement in the gastrointestinal tract.

Choice B rationale

Checking the pH level of gastric contents can help determine if the tube is in the stomach, but it is not the most reliable method. Gastric pH is typically acidic (1.5-3.5), but the pH can vary, and this method does not rule out respiratory placement or other incorrect placements.

Choice C rationale

Auscultating for air insufflation involves listening for the sound of air injected through the tube into the stomach. However, this method is not reliable as it does not confirm the exact location of the tube and can give false positives if the tube is in the esophagus or respiratory tract.

Choice D rationale

Requesting a chest x-ray is the most reliable method for verifying feeding tube placement. It provides a clear visual confirmation of the tube's location, ensuring it is correctly positioned in the stomach or small intestine and not in the respiratory tract or other incorrect locations.

A. A client whose grief response is repressed. B. A client whose grief response begins following a terminal diagnosis. C. A client whose grief response leads to self-destructive behaviors. D. A client whose grief response is triggered by a secondary loss.

Correct Answer is C

Explanation

Choice A rationale

A repressed grief response, where an individual avoids expressing their grief, is considered delayed grief, not exaggerated grief. This can manifest as physical symptoms or psychological issues later on.

Choice B rationale

Grief that begins following a terminal diagnosis is anticipatory grief, which is a normal response as individuals begin to process the impending loss. It prepares them emotionally for the eventual death.

Choice C rationale

Exaggerated grief involves intense, prolonged, and often harmful reactions such as self-destructive behaviors. This type of grief can significantly impair a person's ability to function and may require professional intervention.

Choice D rationale

A grief response triggered by a secondary loss (e.g., loss of job or home) is known as cumulative grief. While it complicates the grieving process, it does not inherently lead to the exaggerated, self-destructive behaviors seen in exaggerated grief.

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A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.Which of the following actions by the AP requires intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking for proper placement of a feeding tube.Which of the following methods is the most reliable for verification of tube placement?

Correct Answer is D

Explanation

A nurse is participating in a group discussion about complicated grief associated with loss.Which of the following should the nurse identify as an example of exaggerated grief?

Correct Answer is C

Explanation

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A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.
Which of the following actions by the AP requires intervention by the nurse?