Which measure should a nurse include in the care plan for a client who has mitt restraints to prevent pulling out tubes?
Removing the mitts when the client is asleep.
Performing range of motion exercises every two hours.
Tying the restraints securely around the wrists and to the bed.
Placing the restraints loosely to allow increased freedom of movement.
The Correct Answer is B
This is because mitt restraints can reduce the patient’s mobility and circulation in the hands, and range of motion exercises can help prevent contractures, stiffness, and edema.
Choice A is wrong because removing the mitts when the client is asleep can increase the risk of self-injury or removal of therapeutic equipment.
Choice C is wrong because tying the restraints securely around the wrists and to the bed can impair the patient’s circulation and cause nerve damage.
Choice D is wrong because placing the restraints loosely to allow increased freedom of movement can cause entanglement or strangulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Schizophrenia is a disorder that has genetic risk factors, but is not caused by a single gene. The risk of developing schizophrenia is higher if you have a close relative with the disorder, but it is not certain. The risk varies depending on the degree of relatedness and the number of genes involved. The heritability of schizophrenia, which measures how much of the risk is due to genetic factors, is estimated to be between 60% to 80%.
Choice B is wrong because it exaggerates the risk of schizophrenia for children of affected parents. The risk is about 10%, not 10 times more than the general public.
Choice C is wrong because it gives a false and misleading statistic.
There is no 50% chance that a child will be born with schizophrenia, and there is no evidence that crowded places and high anxiety situations can cause the disorder.
Choice D is wrong because it is based on false and outdated stereotypes. Females with schizophrenia are not infertile and can carry a full-term pregnancy, but most of the people who are affected are male.
Correct Answer is D
Explanation
Offer a glass of warm milk. According to some studies, warm milk may have a relaxing effect on the body and help induce sleep. It also contains tryptophan, an amino acid that is converted to serotonin and melatonin, which are neurotransmitters that regulate sleep cycles.
Choice A is wrong because a warm shower may increase the body temperature and make it harder to fall asleep.
Choice C is wrong because notifying the healthcare provider is not necessary for a client with insomnia unless there are other signs of distress or complications.
Choice D is wrong because watching television may stimulate the brain and interfere with the production of melatonin, a hormone that promotes sleep.
Some other nursing interventions for insomnia are:
- Educate the patient on the proper food and fluid intake such as avoiding heavy meals, alcohol, caffeine, or smoking before bedtime.
- Evaluate the patient’s sleep hygiene such as having a regular bedtime and wake-up time, avoiding naps during the day, and limiting exposure to light at night.
- Provide a conducive environment for sleep such as reducing noise, adjusting temperature and lighting, and using comfortable bedding.
- Help the patient develop a sleeping plan such as engaging in relaxing activities before bed, avoiding checking the clock, and getting out of bed if unable to sleep after 20 minutes.
- Understand the proper use of sleep aids or other medications such as following the prescription, avoiding over-the-counter drugs without consulting the provider, and being aware of the side effects and interactions.
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