A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?

Request a PRN restraint prescription for clients who are aggressive.

Document the client's condition every 15 min.

Attach the restraint to the bed's side rails.

Remove the client's restraint every 4 hr.

Answer and Explanation

The Correct Answer is B

Answer is: b. Document the client's condition every 15 min.

Explanation: The nurse manager should include the guideline to document the client's condition every 15 minutes while using belt restraints. This is to ensure close monitoring of the client's physical and psychological well-being and to evaluate the ongoing need for restraint use.

Choice a. is wrong because requesting a PRN restraint prescription for clients who are aggressive might not be appropriate. The use of restraints should be based on a thorough assessment of the client's condition and should be the least restrictive method possible.

Choice c. is wrong because attaching the restraint to the bed's side rails poses a safety risk to the client, as the side rails can be lowered accidentally or intentionally, leading to potential injury.

Choice d. is wrong because removing the client's restraint every 4 hours might not be appropriate, as it depends on the client's specific needs, facility policies, and state regulations. The nurse should follow appropriate guidelines for removing restraints and reassess the client's need for continued restraint use.

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Correct Answer is ["A","E"]

Explanation

Choice A rationale:
Contractures are a risk for this client due to the lack of movement and constant positioning on one side. Contractures occur when the muscles, tendons, or ligaments shorten and tighten, limiting range of motion and flexibility. This can be a result of prolonged immobility or lack of use of the muscles.
Choice B rationale:
Calcium resorption is not a risk for this client. Calcium resorption refers to the process where bone tissue is broken down and calcium is released into the bloodstream. This process is not directly related to immobility or multiple sclerosis.
Choice C rationale:
Hypocalcemia, or low calcium levels in the blood, is also not a direct risk for this client. While immobility can lead to bone loss over time, it does not directly cause hypocalcemia.
Choice D rationale:
Diarrhea is not a risk for this client based on the information provided. Diarrhea can be a symptom of many conditions but there is no indication in the scenario that this client is at risk.
Choice E rationale:
Urinary stasis is a risk for this client due to their immobility. When a person is immobile, urine can pool in the bladder, creating an environment where bacteria can grow, potentially leading to urinary tract infections.

A. Swollen area on calf. B. Increased blood pressure. C. Decreased serum calcium levels. D. Urinary frequency.

Correct Answer is A

Explanation

Choice A rationale:

A swollen area on the calf can indicate deep vein thrombosis (DVT), which is a serious complication of immobility. Immobilization can lead to blood stasis in the veins, increasing the risk of clot formation. DVT can result in severe complications, such as pulmonary embolism, making it a critical concern that requires immediate attention.

Choice B rationale:

Increased blood pressure is not a direct complication of immobility. However, immobility can contribute to hypertension over time due to factors such as weight gain and reduced cardiovascular fitness. While hypertension is a concern, it is not an acute complication of immobility that necessitates immediate intervention.

Choice C rationale:

Decreased serum calcium levels are not a direct complication of immobility. Immobility can lead to bone density loss and potential fractures due to reduced weight-bearing activities, but it does not cause an acute decrease in serum calcium levels.

Choice D rationale:

Urinary frequency is not a typical complication of immobility. Immobility can affect the urinary system, potentially leading to urinary stasis and increased risk of urinary tract infections, but urinary frequency is not a direct result of immobility.

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A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse manager include?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","E"]

Explanation

A nurse is caring for a client who is on bed rest.The nurse should recognize that which of the following findings is a complication of immobility?

Correct Answer is A

Explanation

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A nurse manager is updating protocols for the use of belt restraints.
Which of the following guidelines should the nurse manager include?