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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A respiratory therapist is not typically required to assist a stroke client with dysphagia. Their expertise is more focused on respiratory issues rather than swallowing difficulties.
Choice B rationale
A speech therapist is the correct team member to assist a stroke client with dysphagia. Speech therapists specialize in diagnosing and treating swallowing disorders, which are common in stroke patients.
Choice C rationale
A physical therapist focuses on improving a client’s physical mobility and strength. While they play a crucial role in stroke rehabilitation, they are not specifically trained to address dysphagia.
Choice D rationale
A pharmacist’s role is to manage and dispense medications. They do not have the specialized training required to assist with dysphagia.
Correct Answer is C
Explanation
Choice A rationale
Reserving a facility for the program is a logistical step, not a SMART goal. SMART goals should be Specific, Measurable, Achievable, Relevant, and Time-bound. This choice does not meet those criteria.
Choice B rationale
Having clients share their feelings is important for support and motivation, but it is not a SMART goal. It lacks specificity and measurability, making it difficult to assess progress and success.
Choice C rationale
Setting a goal for 50% of the clients to stop smoking within 3 weeks is a SMART goal. It is Specific (50% of clients), Measurable (stop smoking), Achievable (within 3 weeks), Relevant (smoking cessation), and Time-bound (3 weeks). This goal provides a clear target and timeframe for evaluating the program’s effectiveness.
Choice D rationale
Discussing smoking cessation techniques is an important part of the program, but it is not a SMART goal. It lacks specificity and measurability, making it difficult to assess the program’s success.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.