A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

The client reports that the restraints are too tight.

The client has been in the restraints for 4hr.

The client is able to calmly follow commands.

The client can explain the reasons for their behavior.

Answer and Explanation

The Correct Answer is C

A. The client reports that the restraints are too tight: This indicates a need for adjustment of the restraints but does not necessarily indicate that the restraints should be discontinued altogether. The client's ability to follow commands and behave safely is a more critical factor in deciding whether to discontinue the restraints.
B. The client has been in the restraints for 4 hours: While prolonged use of restraints should be avoided due to the risk of complications such as skin breakdown and loss of mobility, the duration alone may not be the sole indicator for discontinuing restraints. The client's behavior and ability to follow commands are more important considerations.
C. The client is able to calmly follow commands: This is the most appropriate finding indicating that the restraints should be discontinued. Calmly following commands suggests that the client's behavior has improved and they are no longer a danger to themselves or others, making the restraints unnecessary.
D. The client can explain the reasons for their behavior: While understanding the reasons for the client's behavior is important for addressing underlying issues, it does not necessarily indicate that the client is no longer a risk to themselves or others. The ability to calmly follow commands is a more immediate concern when deciding whether to discontinue restraints.

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Correct Answer is D

Explanation

A. Loss of central vision: While loss of central vision can occur with various eye conditions, such as age-related macular degeneration, it is not specific to cataracts. Cataracts typically cause clouding of the lens, leading to blurred or dimmed vision rather than loss of central vision.
B. Increased intraocular pressure: Increased intraocular pressure is characteristic of conditions such as glaucoma, not cataracts. Cataracts involve clouding of the lens rather than elevated pressure within the eye.
C. Decrease in peripheral vision: Decreased peripheral vision is associated with conditions like retinitis pigmentosa or glaucoma but is not a typical finding in cataracts. Cataracts primarily affect visual acuity and clarity rather than peripheral vision.
D. A bluish-white colored pupil: A bluish-white appearance of the pupil, known as leukocoria or a white pupil reflex, can be indicative of cataracts. It occurs due to light scattering by the cloudy lens of the eye, resulting in an abnormal reflection from the pupil. This finding is characteristic of cataracts and warrants further evaluation by an ophthalmologist.

A. A child who has acute epiglottitis and is drooling B. A child who has mononucleosis and reports severe fatigue C. A child who has Wilms' tumor and an abdominal mass D. A child who has a urinary tract infection and bright red blood in their urine

Correct Answer is A

Explanation

A. A child who has acute epiglottitis and is drooling: Acute epiglottitis is a medical emergency that can rapidly progress to airway obstruction and respiratory distress. Drooling is a significant sign of airway compromise in children with epiglottitis due to swelling of the epiglottis. This child requires immediate assessment and intervention to ensure airway patency.
B. A child who has mononucleosis and reports severe fatigue: While mononucleosis can cause severe fatigue, it is not an immediate life-threatening condition compared to acute epiglottitis. Assessment and intervention for severe fatigue can be prioritized after addressing the child with potential airway compromise.
C. A child who has Wilms' tumor and an abdominal mass: Wilms' tumor is a type of kidney cancer that typically presents with an abdominal mass. While it requires timely medical intervention, it is not as urgent as acute epiglottitis, which poses a risk of airway obstruction.
D. A child who has a urinary tract infection and bright red blood in their urine: While a urinary tract infection with hematuria requires assessment and treatment, it is not immediately life-threatening compared to acute epiglottitis. Addressing the child with potential airway compromise takes precedence over evaluating and managing hematuria.

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A nurse is assessing a client who is in mechanical restraints after Hitting a staff member. Which of the following findings indicates that the nurse should discontinue the restraints?

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