A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

The restraint tie strap is tied into a knot.

The restraint is attached to the side rails of the bed.

The skin under the restraint is cool and has changed color.

The nurse can insert two fingers under the restraint.

Answer and Explanation

The Correct Answer is D

Rationale:

A. The restraint tie strap is tied into a knot: Restraint straps should be secured using a quick-release or slipknot, not a firm knot. A tight knot can delay removal in an emergency and increases the risk of injury to the client.

B. The restraint is attached to the side rails of the bed: Attaching restraints to side rails is unsafe, as moving the rails can apply excess force or cause injury. Restraints should be secured to a stable part of the bed frame to prevent unintentional tightening or injury.

C. The skin under the restraint is cool and has changed color: Changes in skin temperature or color can indicate impaired circulation, a serious complication of improper restraint use. These findings require immediate attention and potential removal of the restraint.

D. The nurse can insert two fingers under the restraint: Being able to insert two fingers ensures the restraint is snug but not too tight, allowing adequate circulation and reducing the risk of skin breakdown. This is a standard guideline for safe restraint application.

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Correct Answer is B

Explanation

Rationale:

A. Anger: Anger is typically characterized by blaming others, expressing frustration, or resentment toward the situation, self, or those perceived to be responsible. It often follows denial and precedes bargaining in the stages of grief.

B. Bargaining: The statement "If only I had another day with them" reflects bargaining, a grief stage where individuals dwell on what could have been done differently to prevent the loss. This often includes hypothetical thinking or “what if” scenarios as a way to cope with the pain.

C. Denial: Denial involves refusing to accept the reality of the loss. It may manifest as disbelief or numbness, rather than expressing a desire to have more time or change past events, as seen in this client’s statement.

D. Depression: Depression in grief involves deep sadness, withdrawal, or feelings of hopelessness. While the client may be experiencing sorrow, the focus on "if only" thinking indicates bargaining more than the full emotional weight of depression.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"A"}

Explanation

Rationale:

• An endoscopy is necessary to visualize the upper gastrointestinal tract for potential ulcers or bleeding sites, especially given the client’s positive fecal occult blood and anemia. This procedure will help identify active bleeding and confirm a diagnosis of peptic ulcer disease.

• An antifungal prescription is inappropriate because there is no evidence of fungal infection such as thrush or candidiasis. The client’s symptoms and diagnostic findings are more consistent with a gastrointestinal disorder, particularly peptic ulcer disease.

• Oxygen via nonrebreather mask is not indicated because the client's oxygen saturation is normal at 98% on room air. There are no respiratory symptoms or signs of hypoxia that would necessitate supplemental oxygen at this level of intensity.

• Low hemoglobin and hematocrit indicate a state of anemia, which is likely due to chronic gastrointestinal bleeding. The client’s history of dark, tarry stools (melena) further supports ongoing blood loss from the upper GI tract, necessitating diagnostic evaluation.

• History of gnawing epigastric pain is suggestive of peptic ulcer disease but does not on its own justify urgent endoscopy. This history becomes more significant when paired with other alarming signs like bleeding or anemia, but alone it is not a definitive indicator.

• Stool test results showing a positive hemoccult test confirm the presence of gastrointestinal bleeding. Combined with anemia and pain, this is a key indicator for immediate endoscopic evaluation to locate and treat the bleeding source.

• H. pylori results support a peptic ulcer etiology, but the infection alone does not require urgent visualization unless there are complications like bleeding, anemia, or severe symptoms, which would necessitate further diagnostic action.

• Presence of epigastric tenderness is a non-specific physical finding that could result from many conditions and is not sufficient to determine the need for endoscopy without other supportive clinical evidence pointing toward bleeding or ulceration.

• Smoking and alcohol intake history increase the risk for peptic ulcer disease but are not acute indicators for endoscopy. They contribute to the etiology and chronic risk but do not demonstrate the immediate need for invasive diagnostics.

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A nurse is assisting in the care of a client who is placed in wrist restraints. Which of the following should the nurse recognize as an expected finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client whose partner died suddenly in a motor vehicle accident. The partner states, "If only I had another day with them." The nurse should identify the client is experiencing which of the following reactions to the loss?

Correct Answer is B

Explanation

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit. Exhibits Complete the following sentence by using the lists of options. The nurse anticipates the client will likely require dropdown as evidenced by the client's dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"A"}

Explanation

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