Which of the following is essential when restraints are applied to a client?
Use a square knot.
Assess the extremity for circulation and neurological integrity every 2 hours.
Secure the restraint to the side rail.
Assess restraints and skin integrity every 12 hours.
The Correct Answer is B
A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.
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Related Questions
Correct Answer is B
Explanation
A. Inhibits release of endorphins: Exercise actually stimulates the release of endorphins, which are chemicals in the brain that help reduce pain and improve mood. Thus, this statement is incorrect.
B. Improves sleep: Exercise is known to enhance sleep quality by promoting better sleep patterns and reducing insomnia. This is a well-documented benefit of regular physical activity.
C. Decreases energy: Exercise typically increases overall energy levels rather than decreasing them. Regular physical activity helps in maintaining stamina and reducing fatigue.
D. Decreases stress: While exercise does help in managing stress, the primary benefit related to the is the improvement in sleep. Stress reduction is also a significant benefit but not the focus here.
E. Increases mood: Exercise can indeed elevate mood through the release of endorphins and other neurochemicals. However, improving sleep is a more direct and specific benefit related to the about exercise's benefits.
Correct Answer is A
Explanation
A. Current Medical condition: The situation component of ISBARR focuses on the patient's current medical condition and why they are in the facility. It provides a snapshot of the client's immediate situation.
B. List of medications: While important, the list of medications is more relevant to the background or assessment components of the report.
C. Vital signs: Vital signs are part of the assessment, providing data on the client’s current health status.
D. Treatment: Treatment information falls under the recommendation or background sections of the report, detailing the plans or historical context rather than the immediate situation.
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