The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint?

The patient refuses to call for help to go to the bathroom

The patient continues to remove the nasogastric tube

The patient gets confused regarding theme at night

The patient does not sleep and continues to ask for items

Answer and Explanation

The Correct Answer is B

A.   Refusing to call for help does not necessarily indicate a need for restraints.
B.   Removing a nasogastric tube poses a risk to the patient’s health and may require restraints to prevent
harm.
C.   Confusion may warrant closer monitoring, but not necessarily restraints.
D.   Insomnia and asking for items may need intervention but not restraint.

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Correct Answer is A

Explanation

A. Staying in the room allows the nurse to provide direct supervision and education to the nursing assistant on proper catheter care.
B. Asking the nursing assistant to return after leaving the room does not provide immediate guidance and may not address the problem effectively.
C. Discontinuing the catheter may not be necessary; proper care can often resolve cleanliness issues.
D. While documentation is important, immediate action to correct the care is more crucial.

A. Defer the bath until evening and pass on the information to the next shift B. Tell the patient that she must bathe because this is the "normal" routine C. Explain to the patient the importance of maintaining morning hygiene practices D. Cancel hygiene for the day and attempt again in the morning

Correct Answer is A

Explanation

A. Accommodating the patient's preference fosters a positive therapeutic relationship and respects her autonomy.
B. Insisting on a "normal" routine may lead to resistance and decreased trust.
C. Education about hygiene is valuable, but should be tailored to patient preferences.
D. Skipping hygiene entirely is not appropriate; it’s better to find a compromise.

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The nurse is caring for a hospitalized patient. Which of the following behaviors alerts the nurse to consider the need for restraint?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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