A nurse manager is presenting information to the nursing staff regarding the appropriate use of client restraints. Which of the following should the nurse include? (Select all that apply.)
The provider should renew the prescription for restraints every 48 hr.
The nurse should pad the bony prominences.
The nurse should tie the restraints using a square knot.
The nurse should remove the restraints every 2 hr.
The provider's prescription should include the type of restraint to use.
Correct Answer : B,D,E
A. The provider should renew the prescription for restraints every 24 hours, not 48 hours. This ensures regular evaluation of the need for continued restraint use.
B. Padding bony prominences helps prevent skin breakdown and injury from the restraints.
C. Restraints should be tied using a quick-release knot, not a square knot, to allow for rapid removal in case of emergency.
D. Restraints should be released every 2 hours (or as specified by the provider) to assess and provide care for the client's needs and to prevent complications such as skin breakdown or circulation impairment.
E. The provider's prescription should specify the type of restraint to be used, the reason for use, the duration, and any other relevant details to ensure appropriate and safe application.
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Related Questions
Correct Answer is D
Explanation
A. The provider is not required to notify the client's employer about the admission to a mental health facility. This information is protected under confidentiality laws and regulations.
B. While the client may be strongly encouraged to take prescribed medications, they cannot be forced to do so without consent, especially if they are competent to make their own decisions.
C. Electroconvulsive therapy (ECT) typically requires informed consent from the patient or their legal representative, even in an involuntary admission scenario. Therefore, it is incorrect to state that ECT can be performed without consent.
D. If the client poses a risk of harm to themselves or others, the provider can prescribe restraints as a safety measure. This statement is correct and aligns with safety protocols in mental health facilities.
Correct Answer is A
Explanation
A.
A. "Notify your provider if you experience muscle weakness." - Muscle weakness can be a sign of digoxin toxicity and should be reported to the provider immediately.
B. "Report a weight gain of one-half pound per day." - While weight gain can indicate fluid retention, it is not a specific symptom of digoxin toxicity.
C. "Expect this medication to increase your blood pressure." - Digoxin is not typically associated with increasing blood pressure.
D. "You will need to take a diuretic while taking this medication." - Diuretics are not typically required with digoxin unless there are specific indications for their use.
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