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Which of the following is essential when restraints are applied to a client?

A.

Use a square knot.

B.

Assess the extremity for circulation and neurological integrity every 2 hours.

C.

Secure the restraint to the side rail.

D.

Assess restraints and skin integrity every 12 hours.

Answer and Explanation

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 D

Explanation

A. Episodic acute stress: This term is not a recognized diagnosis. Acute stress disorder and posttraumatic stress disorder are the established diagnoses related to trauma and stress.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder characterized by abdominal pain and altered bowel habits. It is not related to the flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after exposure to a traumatic event and involves symptoms like intrusive memories and flashbacks. However, since the traumatic event occurred a year ago, this disorder is less likely than PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by symptoms such as flashbacks, nightmares, and severe anxiety following exposure to a traumatic event. Given the traumatic event happened a year ago, the client’s symptoms are consistent with PTSD.

Correct Answer is B

Explanation

A. Change in marital status: This is a psychological and social stressor rather than a physiological one.
B. Burn injury: A burn injury is a physiological stressor because it directly affects the body's physical systems and functions, causing a stress response.
C. Academic pressure: This represents a psychological and emotional stressor, impacting mental health and well-being, rather than physical systems.
D. Financial difficulties: Financial difficulties are psychological and social stressors, affecting emotional and mental health rather than physiological processes.

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