A nurse assesses a patient with restraints. The nurse should:
Loosen the restraints and assess the patient’s skin.
Document the findings in the patient’s chart.
Continue to monitor the patient without making any changes.
Apply ice packs to reduce swelling.
The Correct Answer is B
Choice A rationale
Loosening the restraints and assessing the patient’s skin is important, but it should be done as part of a regular assessment and not as the first action. The nurse should first document the findings to ensure accurate and timely communication of the patient’s condition.
Choice B rationale
Documenting the findings in the patient’s chart is the correct action. Accurate documentation is essential for communicating the patient’s condition and any interventions performed. It ensures continuity of care and provides a legal record of the patient’s status and the care provided.
Choice C rationale
Continuing to monitor the patient without making any changes is not appropriate. The nurse should assess the patient’s condition and document the findings to ensure that any necessary interventions are performed promptly.
Choice D rationale
Applying ice packs to reduce swelling is not appropriate in this context. The nurse should first document the findings and then assess the need for any interventions based on the patient’s condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Discussing the benefits of losing weight is important, but it is not sufficient on its own. While understanding the benefits can motivate the client, it does not provide the practical steps needed to achieve weight loss. The client needs actionable information and guidance to make sustainable changes.
Choice B rationale
Creating a diet plan for the client can be helpful, but it may not be the most effective approach. A diet plan needs to be personalized and adaptable to the client’s preferences, lifestyle, and medical conditions. Providing learning materials empowers the client to make informed choices and develop their own plan, which is more sustainable in the long term.
Choice C rationale
Encouraging the client to share their feelings is supportive and can help address emotional factors related to weight loss. However, it does not directly provide the practical knowledge and skills needed to achieve weight loss. Learning materials on necessary habits offer concrete steps and strategies for the client to follow.
Choice D rationale
Providing learning materials on necessary habits is the most comprehensive approach. It equips the client with the knowledge and tools needed to make informed decisions about their diet, exercise, and lifestyle. This empowers the client to take control of their weight loss journey and make sustainable changes.
Correct Answer is A
Explanation
Choice A rationale
An advance directive is a legal document that outlines a patient’s wishes regarding medical treatment in situations where they are unable to communicate their decisions. It includes instructions on life-sustaining treatments, resuscitation, and other medical interventions. This ensures that the patient’s preferences are respected and followed by healthcare providers.
Choice B rationale
A document that specifies the final arrangements for the patient is not an advance directive. Final arrangements typically refer to funeral and burial plans, which are not related to medical treatment decisions. Advance directives focus on medical care and treatment preferences.
Choice C rationale
A legal document that designates a person to make healthcare decisions for the patient is known as a durable power of attorney for healthcare or healthcare proxy. While this is an important component of advance care planning, it is not the same as an advance directive. An advance directive specifically outlines the patient’s treatment preferences.
Choice D rationale
A legal document that communicates the patient’s wishes regarding their care is a broader description that can include various types of advance care planning documents. However, the best description of an advance directive is a document that outlines the patient’s wishes regarding medical treatment.
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