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.

Answer and Explanation

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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Correct Answer is ["A","B","C","D"]

Explanation

Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.

Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.

Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.

Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.

The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:

Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.

Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.

A. "You can safely take this medication if you become pregnant." B. "You should expect to have blood work every 6 months while taking this medication." C. "You might experience swollen gums while taking this medication." D. “You can skip a dose of this medication if you are nauseated."

Correct Answer is C

Explanation

Phenytoin is known to cause gingival hyperplasia, which is characterized by swollen and enlarged gums. This side effect is more common in long-term use and may require dental care and regular oral hygiene practices.

Phenytoin is known to be associated with an increased risk of birth defects in babies born to women taking the medication during pregnancy. It is important for women of childbearing age to discuss the risks and benefits of phenytoin with their healthcare provider and use effective contraception to avoid pregnancy while taking the medication.

Phenytoin can affect liver function, so regular monitoring of liver enzymes and blood levels of the medication is necessary. The frequency of blood work may vary depending on the individual's specific situation, so it is important to follow the healthcare provider's instructions. It is not advisable to skip a dose of phenytoin without consulting a healthcare provider.

Abruptly stopping or missing doses of antiepileptic medications can lead to breakthrough seizures or other complications. Any changes in the medication regimen should be discussed with the healthcare provider.

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A nurse is applying a belt restraint to a client who has become physically aggressive. Which of the following actions should the nurse take?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Laboratory Results 1100: Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is C

Explanation

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