A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?
The client has full range of motion in her wrist.
The client is attempting to remove the restraint.
The client has cyanotic digits.
The client denies discomfort.
The Correct Answer is C
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
Fiber is correct. Fiber is essential for maintaining healthy bowel elimination. It helps to add bulk to the stool and promotes regular bowel movements. There are two types of fiber: soluble and insoluble. Soluble fiber absorbs water and forms a gel-like substance, which helps soften the stool and make it easier to pass. Insoluble fiber adds bulk to the stool and helps it move through the digestive tract more quickly.
Choice B Reason:
Fat is incorrect. While fats are an important part of a balanced diet, they do not play a primary role in maintaining healthy bowel elimination. Fats are essential for energy and the absorption of fat-soluble vitamins, but they do not have the same effect on bowel movements as fiber.
Choice C Reason:
Protein is incorrect. Protein is crucial for building and repairing tissues, but it does not directly influence bowel elimination. A diet high in protein without adequate fiber can sometimes lead to constipation.
Choice D Reason:
Minerals are incorrect. Minerals are vital for various bodily functions, including bone health, fluid balance, and muscle function. However, they do not directly impact bowel elimination in the same way that fiber does.
Correct Answer is D
Explanation
Choice A Reason:
Sleep deprivation is incorrect. While sleep deprivation can cause confusion and disorientation, it is less likely to cause abrupt onset of altered mental status and hallucinations. Sleep deprivation typically results in gradual cognitive decline and fatigue rather than sudden changes.
Choice B Reason:
Normal signs of aging is incorrect. Normal aging can involve some cognitive decline, but it does not typically cause sudden and severe symptoms like hallucinations and significant disorientation. These symptoms are more indicative of an acute condition.
Choice C Reason:
Dementia is incorrect. Dementia involves a gradual decline in cognitive function over time and does not typically present with sudden onset of symptoms. While dementia can include hallucinations and disorientation, these symptoms usually develop progressively.
Choice D Reason:
Delirium is correct. Delirium is characterized by a sudden onset of confusion, disorientation, and changes in mental status. It is often triggered by acute medical conditions such as infections, including UTIs. Elderly patients are particularly susceptible to delirium, which can include symptoms like hallucinations and severe confusion.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today