The nurse is caring for a patient who is confused and agitated. The patient continues to get out of bed without assistance and is at high risk for falls. The nurse is considering alternatives to implement prior to applying restraints.
Of the following, which would the nurse NOT consider in the plan of care as an alternative to restraints?
Give the patient something to do while in bed, such as a coloring book or puzzle.
Play music or video selections of the patient's choice.
Place all 4 side rails up to prevent the patient from getting out of bed and falling.
Reduce stimulation noise, and light to calm the patient.
The Correct Answer is C
The correct answer is choice C, Place all 4 side rails up to prevent the patient from getting out of bed and falling.
When considering alternatives to restraints for a confused and agitated patient who is at high risk for falls, placing all 4 side rails up to prevent the patient from getting out of bed and falling is not an appropriate alternative. This action can be considered as restraint use and can increase the patient's agitation and risk for injury. Instead, the nurse should provide the patient with activities to do while in bed, play music or video selections of the patient's choice, and reduce stimulation noise and light to calm the patient.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.2"]
Explanation
Each mL contains 5,000,000 units. Therefore, to administer 1,000,000 units, we need:
1,000,000 units / 5,000,000 units/mL = 0.2 mL
So, the nurse will give 0.2 mL of reconstituted penicillin G to the client.
Correct Answer is C
Explanation
The correct answer is choice C: "The doctors must have made a mistake." KüblerRoss defines five stages of psychosocial responses to dying and death: denial, anger, bargaining, depression, and acceptance. Denial is the first stage, characterized by a refusal to accept the reality of the situation. In this stage, individuals may use defense mechanisms to cope with the overwhelming emotions associated with their diagnosis or prognosis. The statement "The doctors must have made a mistake" is an example of denial as the individual refuses to accept the diagnosis and instead attributes it to an error by medical professionals.
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