A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

Determine if the client has a support system.

Schedule a mental health consult for the client.

Provide the client with information about coping strategies.

Encourage the client to attend a support group.

Answer and Explanation

The Correct Answer is A

A)   Determine if the client has a support system. - Assessing the client's current support network is essential to determine available resources and potential interventions.
B)   Schedule a mental health consult for the client. - While mental health support may be necessary, understanding the client's existing support system is the first step.
C)   Provide the client with information about coping strategies. - Providing coping strategies is important but should come after assessing the client's support system.

D)   Encourage the client to attend a support group. - Encouraging attendance at support groups can be helpful, but it's important to assess the client's current support system first.

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Correct Answer is ["A","C","E"]

Explanation

A) Observe the client's skin integrity every 2 hr. - Regular skin assessments are essential to monitor for any signs of skin breakdown or injury related to the use of restraints.
B) Use a square knot to secure the client's restraint to the bed. - A quick-release knot, not a square knot, should be used to secure restraints for easy removal in case of an emergency.

C) Ensure that 2 fingers can be placed between the restraint and the client. - This ensures that the restraint is not too tight, allowing for circulation and preventing injury.
D) Tie the ends of the restraint to the client's bed rail. - Restraints should not be tied to the bed rail as it can increase the risk of injury and entrapment.
E) Pad bony prominences before applying a restraint. - Padding bony prominences helps prevent pressure injuries and discomfort for the client.

A. Placing the restraint across the client's chest B. Applying the restraint over the client's gown C. Using a quick-release tie to secure the restraint D. Tying the restraint to the bed frame

Correct Answer is A

Explanation

A) Placing the restraint across the client's chest - This is not a safe practice since it can restrict breathing increasing the risk of asphyxiation.
B) Applying the restraint over the client's gown - Restraints should be applied over the clients gown and not directly to the client's skin to prevent friction and skin breakdown.
C) Using a quick-release tie to secure the restraint - Quick-release ties are important for ensuring that restraints can be quickly removed in case of an emergency.
D) Tying the restraint to the bed frame – Tying restraints on the bed frame is the recommended practice. Restraints should not be tied on the bed rails to avoid injuries if the side rails are released.

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A nurse is assisting with the care of a client who has a recent diagnosis of a chronic condition and is exhibiting findings of ineffective coping. Which of the following actions should the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse at a long-term care facility is reinforcing teaching with a newly licensed nurse about the proper use of restraints. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","C","E"]

Explanation

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Correct Answer is A

Explanation

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