A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

The client's hand is cool and pale

The client has full range of motion in her wrist

The client is attempting to remove the restraint.

The client has a capillary refill of less than 2 seconds.

Answer and Explanation

The Correct Answer is A

A) The client's hand is cool and pale: A cool and pale hand suggests decreased circulation, which could be due to the restraint being too tight and impeding blood flow. Loosening the restraint can improve circulation and prevent complications such as tissue damage or nerve injury.
B) The client has full range of motion in her wrist: While it's important to ensure that the client can move comfortably within the restraint to prevent stiffness and maintain circulation, full range of motion alone may not necessitate loosening the restraint. However, if the client's movements are restricted or uncomfortable due to the tightness of the restraint, loosening may be necessary.
C) The client is attempting to remove the restraint: This indicates that the restraint may be too loose or improperly applied, allowing the client to manipulate it easily. The nurse should assess the fit of the restraint and adjust it as needed to prevent the client from removing it while still ensuring safety and appropriate immobilization.
D) The client has a capillary refill of less than 2 seconds: While a rapid capillary refill indicates good circulation, it alone may not warrant loosening the restraint. However, if the client experiences discomfort or other signs of impaired circulation despite rapid capillary refill, the restraint may need adjustment to alleviate pressure and improve circulation.

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Correct Answer is C

Explanation

A) Gelatin: Gelatin is a suitable choice for a clear liquid diet. It is transparent and easily digestible, making it appropriate for individuals requiring clear liquids, such as those recovering from certain medical procedures or surgeries.

B) Popsicle: Popsicles are commonly included in clear liquid diets. They provide hydration and can help soothe a sore throat or provide relief from nausea. However, it is essential to ensure that the popsicle is clear and does not contain any solid fruit or pieces.

C) Yogurt: Yogurt is not typically included in a clear liquid diet. Clear liquid diets consist of transparent or translucent fluids that are easily digested and leave minimal residue in the gastrointestinal tract. Yogurt, being a semi-solid food, contains particles that are not clear and is typically considered a full liquid or soft diet item rather than a clear liquid. Therefore, the client's choice of yogurt indicates a need for further teaching regarding appropriate food choices for a clear liquid diet.

D) Broth: Broth, such as chicken or beef broth, is a staple of clear liquid diets. It is easily digested and provides essential electrolytes and hydration. Broth can be consumed hot or cold, depending on the client's preference and medical condition.

A. Cancer pain B. Acute pain C. Chronic pain D. Neuropathic pain

Correct Answer is A

Explanation

A. Cancer pain: Cancer pain can result from tumor growth, tissue invasion, or nerve compression caused by cancer. It can be acute or chronic and may vary in intensity. However, in this scenario, the client's pain is specifically associated with dermatitis resulting from radiation therapy, rather than directly from the cancer itself.

B. Acute pain: Acute pain is typically sudden in onset and is often associated with tissue injury or damage. In this case, the painful dermatitis resulting from radiation therapy would be considered acute pain because it is directly related to the recent tissue damage caused by the radiation. Acute pain is usually short-term and resolves as the underlying cause heals or is treated.

C. Chronic pain: Chronic pain persists beyond the expected time for tissue healing and is often associated with conditions such as arthritis or neuropathy. While cancer pain can sometimes become chronic if it persists over time, the pain described in this scenario is more likely to be acute given its association with recent radiation therapy.

D. Neuropathic pain: Neuropathic pain results from damage or dysfunction of the nervous system and can present as shooting or burning sensations. While neuropathic pain can occur in cancer patients, the pain described in this scenario is more likely to be acute and related to tissue damage from radiation therapy rather than neuropathy.

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A nurse is assessing a client who has a wrist restraint applied. For which of the following findings should the nurse loosen the restraint?

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