A nurse is caring for a client in a clinic.

Exhibits

For each body system below, click to specify the adverse effect that the nurse should include in the teaching. Choose the most likely response for the dropdown(s) in the table below by choosing from the lists of options.

Body System	Common Adverse Effects
Head, eyes, ears, nose, and throat (HEENT)	dropdown
Cardiovascular	dropdown
Genitourinary	dropdown
Gastrointestinal	dropdown

Note: Each drop down must have 1 response selected.

A. Return in two weeks for a follow up MRI: Clients with an implantable cardioverter/defibrillator (ICD) should generally avoid MRI unless the device is specifically labeled MRI-compatible. Magnetic fields can interfere with the ICD’s function and pose serious risks.
B. Wear loose-fitting clothing: Loose clothing prevents friction or pressure over the ICD insertion site, which promotes comfort and reduces the risk of irritation or infection during the healing period after implantation.
C. Expect to have a rapid pulse rate for the first few weeks: A rapid pulse is not an expected finding after ICD placement. If it occurs, it could indicate arrhythmia or improper device function, and should be evaluated promptly.
D. Resume tub baths and swimming after 24 hr: Immersing the incision site in water within 24 hours increases the risk of infection. Clients are typically advised to avoid submerging the area until the incision has fully healed, usually after 2-4 weeks.

A. “I should assess the client's skin integrity every 8 hours while in mechanical restraints.”: Skin integrity should be assessed much more frequently, typically every 1 to 2 hours, to prevent pressure injuries and ensure circulation is not impaired.
B. “I should expect the provider to evaluate the client within 4 hours of restraint application.”: Provider evaluation is required sooner, generally within 1 hour of restraint application, to ensure the necessity and appropriateness of restraints.
C. “I should ask the provider to write a prescription for mechanical restraints as needed.”: Restraints require a specific, time-limited provider order; PRN (as needed) orders are not appropriate because continuous assessment is necessary to determine ongoing need.
D. “I should visually monitor the client continuously when in mechanical restraints.”: Continuous visual monitoring is essential to ensure the client’s safety, prevent injury, and assess for any distress while restraints are in place.