The nurse is assessing the client's vital signs and is aware that which assessment data requires immediate attention?

The correct answer is choice a. Retie the restraint straps with a slipknot.

Choice A rationale:

The restraint straps should be tied with a slipknot to ensure that they can be quickly released in case of an emergency. A double knot, as currently used, may delay the removal of the restraints when quick release is necessary.

Choice B rationale:

It is important to check that there is enough space for two fingers to fit beneath the restraints, not three. This ensures that the restraints are secure but not too tight, which could impede circulation.

Choice C rationale:

Restraint straps should not be tied to the side rails because if the side rails are lowered, the restraints could become too tight and cause injury. Instead, they should be secured to a part of the bed frame that moves with the patient.

Choice D rationale:

The padding under the wrist restraints should not be removed as it provides a cushion between the restraints and the patient’s skin, which helps prevent injury and ensures the patient’s comfort.

Choice A rationale:

Drinking something cold can lower the oral temperature temporarily. When a person consumes something cold, the blood vessels in the mouth can constrict, leading to a lower temperature reading. However, it's important to note that this effect is temporary.

Choice B rationale:

Exercising can increase blood circulation and raise body temperature. However, immediately after intense physical activity, the body might start sweating, leading to a temporary drop in temperature. Prolonged or moderate exercise, on the other hand, generally increases body temperature.

Choice C rationale:

An outdoor temperature of 99°F does not directly affect body temperature. Body temperature is regulated internally and does not fluctuate based on external temperatures unless the person is exposed to extreme conditions for a prolonged period.

Choice D rationale:

A cold climate might lower skin temperature, but it does not necessarily reduce the body's core temperature significantly. The body has mechanisms to conserve heat in colder environments.

Choice E rationale:

Physical inactivity can lower body temperature, especially in situations where the person is sedentary for an extended period. Reduced physical activity can slow down metabolic processes, leading to a lower body temperature.