When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?
Tie the restraints to the side rail.
Remove the restraints every 3 hr.
Remove one restraint at a time.
Secure restraints with a square knot.
The Correct Answer is C
When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.
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Related Questions
Correct Answer is B
Explanation
Assisting with ambulation for a client who has a pulmonary infection.
Assistive personnel can perform basic nursing care functions such as assisting patients with mobility.
Choice A is wrong because showing a client how to use an incentive spirometer prior to surgery requires more specialized knowledge and training.
Choice C is wrong because irrigating a client’s infected surgical wound is a more complex medical procedure that should be performed by a licensed nurse.
Choice D is wrong because inserting a glycerin suppository for a client who is constipated is also a more complex medical procedure that should be performed by a licensed nurse.
Correct Answer is D
Explanation
This statement indicates that the client understands the importance of gradually adjusting to wearing a hearing aid.
It can take time for the brain to adapt to new sounds and volume levels, so it’s important to increase usage gradually.
Choice A is wrong because turning the hearing aid up as high as it will go can cause discomfort and may not improve hearing.
Choice B is wrong because hearing aids typically last several years with proper care and maintenance.
Choice C is wrong because it’s important to remove the battery from the hearing aid when not in use to preserve battery life.
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