A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?
Apply the restraint under the client's clothes.
Tie the restraint to the railing of the client's bed.
Place the client in a sitting position.
Ensure the restraint is placed across the client's chest.
The Correct Answer is C
a. Applying the restraint under the client's clothes: Restraints should be applied over the client's clothes to avoid direct skin contact and reduce the risk of skin irritation or injury.
b. Tying the restraint to the railing of the client's bed: Restraints should not be tied to bed rails or any other fixed objects. This can increase the risk of injury to the client and should be avoided.
c. Placing the client in a sitting position is appropriate when applying a belt restraint, as it helps prevent respiratory compromise and allows the client to maintain a safer and more comfortable posture.
d. A belt restraint should be placed around the client's waist, not across the chest, to avoid restricting breathing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Insulin lispro is a rapid-acting insulin, while insulin glargine is a long-acting insulin. It is important to keep them separate to maintain their individual properties and avoid any potential interactions or changes in their effectiveness.
Insulin glargine is a clear solution and should not appear cloudy. Cloudiness in insulin can indicate contamination or improper storage.
The instruction to "take an extra dose of insulin lispro prior to aerobic exercise" is not recommended. The client should consult with their healthcare provider to determine if any adjustments to their insulin regimen are necessary for exercise. Typically, adjustments are made based on the individual's blood glucose levels and anticipated intensity and duration of exercise. Insulin glargine is a long-acting insulin that provides a steady release of insulin over a prolonged period, without distinct peaks or valleys in its action. Its onset of action is gradual and its effect lasts for approximately 24 hours.
It is important for the client to receive accurate and appropriate instructions regarding their insulin regimen. The nurse should clarify any misunderstandings and provide accurate information to promote safe and effective diabetes management.
Correct Answer is B
Explanation
The plantar Babinski reflex is assessed by stroking the sole of the foot from the heel towards the toes. A normal response is the flexion or curling of the toes. An abnormal response, known as a positive Babinski sign, is the extension and fanning out of the toes, which indicates an upper motor neuron lesion.
"Place your foot in my hand and I will tap the back of your heel": This instruction is more relevant to testing the Achilles tendon reflex, where the nurse taps the back of the heel to elicit a plantarflexion response.
"Sit on the edge of the bed while I tap your knee": This instruction is more relevant to testing the patellar reflex, also known as the knee-jerk reflex. The nurse taps the patellar tendon just below the kneecap to elicit a reflexive contraction of the quadriceps muscle.
"Relax your arm across your chest and I will test your elbow extension": This instruction is more relevant to testing the triceps reflex, where the nurse taps the triceps tendon to elicit a reflexive extension of the elbow.
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