The nurse is caring for a client who is in the final stages of cancer, is depressed and distant.
The client asks the nurse, "Why is God punishing me?" Which would be the most appropriate action for the nurse to take?

Choice B rationale:

Isometric exercises involve contracting muscles without changing the length of the muscle or joint angle. In this case, squeezing the gluteal muscles tightly constitutes an isometric exercise. Isometric exercises are often used in rehabilitation settings to strengthen specific muscle groups without putting too much strain on the joints.

Choice A rationale:

Option A describes a range of motion exercise involving the wrist, which is not an isometric exercise. Isometric exercises focus on static muscle contractions, not dynamic movements like circular motions.

Choice C rationale:

Lifting a 5-pound weight to increase arm strength involves isotonic exercise, not isometric exercise. Isotonic exercises involve muscle contractions with movement and changing muscle length, unlike isometric exercises, where muscle length remains constant.

Choice D rationale:

Bending the knee up to the chest is an example of a range of motion exercise and does not constitute an isometric exercise. Range of motion exercises involve moving joints through their full extent, but isometric exercises involve static muscle contractions without joint movement.

Choice A rationale:

Applying ankle restraints but leaving the wrists unrestrained is not a balanced approach. Restraints should only be used when necessary and should be applied correctly following the healthcare facility's policies and guidelines. Applying restraints to one part of the body while leaving another unrestrained can lead to injuries and is not a safe practice.

Choice B rationale:

Tying a double knot that is difficult to undo can be dangerous in emergency situations. Restraints should allow for quick release in case of emergencies, ensuring patient safety. Difficult-to-undo knots can delay the removal of restraints, leading to potential harm to the patient.

Choice C rationale:

Tying a slip knot to the side rails of the bed is unsafe and against restraint protocols. Slip knots can tighten when pulled, increasing the risk of injury to the patient. Restraints should be applied to designated areas and never tied to movable parts of the bed or other objects in the room.

Choice D rationale:

Checking on the patient frequently is the most appropriate action when a patient is in restraints. Regular monitoring ensures the patient's safety and well-being, assesses their comfort, and allows for prompt response to any signs of distress or discomfort. Frequent checks also help in preventing complications associated with immobilization, such as pressure ulcers and impaired circulation.