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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse should intervene when the AP raises all four side-rails on the client's bed. While it is important to ensure the client's safety and minimize the risk of falls, raising all four side-rails can be considered a restraint and may not be the best practice for fall prevention. The use of physical restraints, including all four side-rails, can lead to adverse outcomes such as entrapment, increased agitation, and decreased mobility.
Locking the wheels on the client's bed: This is an appropriate action to prevent the bed from rolling and ensures stability.
Clearing furniture from the path leading to the bathroom: This is a good practice as it creates a clear and safe path for the client to walk without obstacles.
Assisting the client to the bathroom every 2 hours: This is a proactive measure to prevent falls by ensuring regular toileting and minimizing the need for the client to get up and move independently.
It's important to promote mobility and independence for the client while ensuring their safety.
Correct Answer is C
Explanation
When collecting data from a child with pertussis (whooping cough), the nurse should expect the following manifestations:
- Paroxysmal cough: The hallmark symptom of pertussis is a severe, uncontrollable cough that often occurs in bursts (paroxysms) followed by a characteristic "whooping" sound as the child inhales.
- Posttussive vomiting: The coughing spells can be so severe that they may lead to vomiting.
- Inspiratory whoop: As mentioned earlier, during the inhalation phase after a coughing episode, the child may make a distinctive whooping sound.
- Cyanosis: The prolonged coughing episodes can sometimes cause the child's face to turn blue (cyanosis) due to inadequate oxygen intake.
- Fatigue and exhaustion: The frequent and intense coughing episodes can be exhausting for the child, leading to fatigue and sleep disturbances.
Other possible manifestations of pertussis can include a mild fever, runny nose, and sneezing. However, these symptoms are less specific to pertussis and can be seen in other respiratory infections as well.
The manifestations listed in the question (beefy, red tongue; facial erythema; peeling of the hands and feet) are not typically associated with pertussis and may be indicative of other conditions or diseases. It is important to consult a healthcare provider for a proper evaluation and diagnosis.
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