A nurse is assessing a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?

The client's hand is cool and pale.

The client has a capillary refill of 1 second.

The client has full range of motion in her wrist.

The client is attempting to remove the restraint.

Answer and Explanation

The Correct Answer is A

A. The client's hand is cool and pale: This indicates impaired circulation due to the restraint being too tight-a serious complication.
B. The client has a capillary refill of 1 second: This is a normal finding and indicates adequate perfusion.
C. The client has full range of motion in her wrist: This is a positive finding, not a complication.
D. The client is attempting to remove the restraint: This suggests agitation or discomfort but not necessarily a physical complication like impaired circulation.

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Correct Answer is A

Explanation

A. Hold the cane on the left side: The cane should be held on the stronger (unaffected) side (in this case, the left) to provide balance and support for the injured right leg.
B. Place the cane 46 cm (18 in) in front of her feet before advancing: The cane should only be placed about 15–25 cm (6–10 in) in front to maintain stability.
C. Adjust the height of the cane so the arm is straight during use: The elbow should be slightly flexed (~20–30 degrees) for optimal balance and comfort.
D. Remove the rubber tip from the end of the cane: The rubber tip is essential for traction and to prevent slipping.

A. Circumduction B. Adduction C. Internal rotation D. Hyperextension

Correct Answer is D

Explanation

A. Circumduction: This is a circular motion combining flexion, extension, abduction, and adduction-like making circles with the leg.
B. Adduction: This is movement toward the midline of the body, not backward.
C. Internal rotation: This involves rotating the leg inward, not moving it backward.
D. Hyperextension: Hyperextension refers to movement beyond the normal extension range, such as moving the leg behind the body while standing.

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A nurse is assessing a client who has a wrist restraint in place. Which of the following findings should the nurse identify as an indication of a complication of the restraint?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following instruction should a nurse provide to promote the safe use of a cane as an assistive device for a client who is recovering from a musculoskeletal injury of the right lower extremity?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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