A nurse is planning care for a client who requires bilateral arm restraints because the client is delirious and attempting to pull out a urinary retention catheter. Which information is important to consider when planning care for this client? Select All That Apply.
Use of restraints adequately prevents injuries.
Laws permit the use of restraints when specific guidelines are followed.
Reasons for use of restraints must be clearly documented.
Most clients recognize that restraints contribute to their safety.
Restraints needed in an emergency require a provider's prescription before application.
Correct Answer : B,C
Physical restraints are last-resort safety measures requiring legal regulation, ethical justification, continuous assessment, and strict documentation. Indications include imminent harm risk, with mandates for time-limited use, monitoring circulation, and preserving dignity to prevent complications.
Rationale:
A. Restraints do not reliably prevent injuries and may increase risk of harm such as strangulation, pressure injury, or psychological distress. Their use can worsen agitation. This reflects poor safety outcomes and increased injury risk, making this statement incorrect.
B. Laws allow restraint use only under strict conditions, including necessity, least restrictive measures, and time limitation. Facilities must follow regulatory standards to protect clients. This emphasizes legal compliance and adherence to established guidelines governing restraint application.
C. Clear documentation of the reason for restraint use is mandatory to justify necessity and ensure accountability. Records must include behavior, alternatives attempted, and ongoing assessment. This supports legal protection and accurate clinical documentation in restraint management.
D. Many clients do not perceive restraints as protective and may experience fear, agitation, or loss of autonomy. This can worsen delirium and behavioral disturbances. This reflects impaired patient perception and negative psychological response, making the statement incorrect.
E. In emergencies, restraints may be applied immediately to prevent harm, but a provider prescription must be obtained promptly afterward. Prior prescription is not required in urgent situations. This reflects correct emergency protocol but incorrect timing requirement as stated.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.6"]
Explanation
Step 1: Identify desired dose and concentration
Desired dose = 3000 units, Concentration = 5000 units/mL
Step 2: Use the formula
Volume (mL) = Desired dose ÷ Concentration
Step 3: Insert values
= 3000 ÷ 5000
Step 4: Calculate
= 0.6 mL
Step 5: Round to the nearest tenth
= 0.6 mL
Correct Answer is A
Explanation
Dietary adherence in the Muslim faith is governed by Halal requirements, which categorize foods as permissible or forbidden based on religious law. Practicing individuals avoid substances designated as Haram, focusing instead on meats prepared through specific ritual slaughter and plant-based nutrition. Understanding these religious constraints is essential for nurses to provide culturally competent care and ensure adequate nutritional intake during hospitalization.
Rationale:
A. Poultry is a primary source of permissible protein provided it has been slaughtered according to Islamic guidelines. In most clinical settings, plain chicken is recognized as an acceptable option for clients following a Halal diet. It serves as a safe alternative to other restricted meats, ensuring the client receives essential amino acids for healing and metabolic function.
B. Consumption of swine products is strictly prohibited under Islamic law and represents one of the most significant dietary restrictions. Pork chops contain enzymes and proteins that are considered ritually impure, making them completely unacceptable for a practicing Muslim client. The nurse must ensure that all meal trays are strictly screened to prevent the inclusion of any porcine derivatives.
C. Most commercial sausages are made from pork or contain non-Halal additives and casings that violate religious dietary standards. Even if the meat is beef-based, it must be certified Halal to be considered permissible for consumption. Providing standard processed meats poses a high risk of violating the client’s religious beliefs and spiritual well-being.
D. Alcohol is classified as an intoxicant and is strictly forbidden for consumption in the Muslim faith. This restriction extends to beverages and often includes food items prepared with alcohol as an ingredient or flavoring agent. The nurse must verify that both the diet and any liquid supplements are free from ethanol content to maintain cultural safety.
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