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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client cannot change their mind after signing consent. Clients have the right to withdraw consent at any time before the procedure begins.
B. The alternative treatments to the procedure should be explained. Informed consent includes information about alternative treatments and their risks/benefits so the client can make an informed decision.
C. The time of the procedure should be indicated on the form. The time of the procedure is not a required component of informed consent. The consent form should include the procedure details, risks, benefits, and alternatives
D. The charge nurse should review the form once it's signed. While nurses witness informed consent, they do not validate or review it. The provider performing the procedure is responsible for obtaining consent.
Correct Answer is D
Explanation
A. "Do you have difficulty sleeping at night?" – While sleep disturbances are common in PTSD, this question assesses symptoms rather than support systems.
B. "How do you feel about the current status of your life?" – This question may provide insight into the client’s emotional state but does not directly assess their support systems.
C. "Have you noticed changes in your eating patterns?" – Changes in appetite can occur with PTSD, but this question focuses on physical symptoms rather than support systems.
D. "Are you comfortable discussing the disaster with your family or friends?" – This is the best choice because it directly assesses whether the client has a support system in place and feels comfortable relying on them for emotional support.
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