A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?
"Remove clocks from the client's room."
"Check on the client frequently while he is in the restroom."
"Encourage physical activity throughout the day to expend energy."
"Use full-length side rails on the client's bed."
The Correct Answer is C
A. "Remove clocks from the client's room." –
Removing clocks can increase confusion and disorientation. Instead, having a visible clock and calendar can help the client stay oriented.
B. "Check on the client frequently while he is in the restroom." –
While frequent monitoring is important, excessive surveillance may increase agitation and distress. A better alternative is to ensure the restroom is safe and accessible.
C. "Encourage physical activity throughout the day to expend energy." –
Engaging the client in physical activity helps reduce restlessness, promotes better sleep, and decreases the likelihood of agitation, which can reduce the need for restraints.
D. "Use full-length side rails on the client's bed." –
Full-length side rails can be considered a form of restraint as they may limit movement and increase the risk of falls or injury if the client tries to climb over them.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
- Oxygen Saturation (90%) – This is a drop from the initial 95% and indicates potential hypoxia. The increased respiratory rate and depth may be compensatory mechanisms.
- Behavioral Findings ("I feel like something is wrong.") – Clients experiencing early signs of deterioration often report a sense of unease. This, combined with agitation, could indicate worsening hypovolemia or hypoxia.
The client's low hemoglobin (8.3 g/dL) and hematocrit (32%) suggest significant blood loss during surgery, which could contribute to hypoxia and hemodynamic instability. Immediate follow-up is needed to assess for potential ongoing bleeding, oxygenation issues, or early signs of shock.
Correct Answer is C
Explanation
A. "Rhythmic respirations." Normal, rhythmic breathing is not typically associated with pain. Pain may cause labored, irregular, or rapid breathing.
B. "Absent cry." The FLACC scale assesses crying as an indicator of pain. However, an absent cry does not suggest pain. A strong, continuous cry or moaning may indicate discomfort.
C. "Resisting care." Clients with pain often resist movement, care, or interventions due to discomfort or distress. This is a key indicator of pain in the FLACC scale (Activity or Consolability sections).
D. "Relaxed posturing." A relaxed posture suggests comfort, while pain often leads to rigid or tense positioning.
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