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

Tying the restraint to the bed frame

Applying the restraint over the client's gown

Placing the restraint across the client's chest

Using a quick-release knot to secure the restraint

Answer and Explanation

The Correct Answer is C

A) Tying the restraint to the bed frame: This action is appropriate and ensures that the restraint is anchored securely to the bed frame, preventing the client from removing it independently. Tying the restraint to the bed frame is a standard practice to maintain the client's safety.

B) Applying the restraint over the client's gown: While it's generally preferable to apply restraints directly to the client's skin to minimize movement and ensure effectiveness, applying the restraint over the gown is acceptable in some situations. However, it's essential to ensure that the restraint is snug and properly secured to prevent the client from slipping out of it.

C) Placing the restraint across the client's chest: Placing the restraint across the client's chest is not recommended because it can restrict chest expansion and interfere with breathing, potentially leading to respiratory compromise. Restraints should be applied to minimize movement while allowing the client to breathe comfortably.

D) Using a quick-release knot to secure the restraint: Using a quick-release knot is essential when applying restraints to ensure that they can be quickly removed in case of an emergency or if the client experiences distress. This promotes client safety and allows for rapid intervention if needed.

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Correct Answer is D

Explanation

A) The client reports insomnia:

Insomnia is a common symptom in Parkinson's disease but may not pose an immediate threat to the client's health or require urgent intervention compared to other symptoms such as difficulty swallowing.

B) The client requires additional help to stand:

While needing assistance to stand is indicative of the progression of Parkinson's disease and may require attention, it is not typically considered a priority over symptoms that directly impact the client's safety and well-being.

C) The client has increased difficulty dressing:

Increased difficulty dressing is a manifestation of Parkinson's disease progression and may impact the client's independence and quality of life. However, it is not as immediately life-threatening as difficulty swallowing.

D) The client has difficulty swallowing:

Difficulty swallowing, or dysphagia, is a serious concern in Parkinson's disease as it can lead to aspiration, malnutrition, dehydration, and respiratory complications such as pneumonia. It poses a significant risk to the client's safety and requires prompt attention to prevent complications. Therefore, it is the priority finding to report at the interprofessional care conference.

A. Medication administration record B. Name of facility social worker C. Need for special equipment D. Health insurance information

Correct Answer is C

Explanation

A) Medication administration record:

While the medication administration record (MAR) is an essential component of the client's medical records and care plan, it may not be directly relevant to the transfer report between healthcare facilities. The MAR typically remains with the client's medical records and is not routinely included in transfer reports. However, information about the client's current medications and any changes in medication regimen may be communicated as part of the transfer report.

B) Name of facility social worker:

While the name of the facility's social worker may be important for ongoing coordination of care and support services, it is not typically included in the transfer report between healthcare facilities. Communication between social workers may occur separately as part of the transition planning process, but it is not a standard component of the transfer report.

C) Need for special equipment:

When transferring a client from one healthcare setting to another, such as from an acute care unit to a long-term care facility, it is crucial to communicate any specific needs or requirements the client may have, including the need for special equipment. This information ensures that the receiving facility is adequately prepared to meet the client's needs upon arrival and can arrange for the necessary equipment or resources to be available. Examples of special equipment may include mobility aids (wheelchair, walker), assistive devices (hearing aids, oxygen concentrators), or specialized medical equipment (wound care supplies, catheters).

D) Health insurance information:

Health insurance information, including details about the client's coverage, billing, and insurance provider, is essential for financial and administrative purposes but may not be directly relevant to the transfer report between healthcare facilities. However, if specific insurance requirements or authorizations are necessary for the client's care at the receiving facility, this information should be communicated as part of the transfer process.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a long-term care facility is collecting data for an interprofessional care conference for a client who has Parkinson's disease. Which of the following findings is the priority for the nurse to report at the conference?

Correct Answer is D

Explanation

A nurse is assisting with the discharge of a client from an acute care unit to a long-term care facility. Which of the following should the nurse include in the transfer report?

Correct Answer is C

Explanation

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