A nurse is providing education about when health care referrals would be appropriate. When should a healthcare provider order a referral?

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.

Choice A Reason:

“Records that the client sees the procedure as necessary” is incorrect. The nurse’s role in signing the consent form is not to document the client’s perception of the necessity of the procedure. This responsibility typically falls to the healthcare provider who explains the procedure and its necessity to the client.

Choice B Reason:

“Determines the client does not have a mental illness” is incorrect. While assessing the client’s mental status is part of the overall care, the nurse’s signature on the consent form does not specifically indicate this. The nurse’s role is to witness the client’s signature and ensure they are giving informed consent.

Choice C Reason:

“Assists that the nurse has explained the risks and benefits of the procedure” is incorrect. It is the responsibility of the healthcare provider performing the procedure to explain the risks and benefits. The nurse may reinforce this information but does not primarily provide it.

Choice D Reason:

“Confirms the client is competent to provide consent” is correct. The nurse’s signature on the consent form indicates that the nurse has witnessed the client signing the form and has verified that the client is competent to provide informed consent. This includes ensuring the client understands the information provided and is making the decision voluntarily.