A nurse is caring for a client who has fluid volume excess. Which of the following manifestations should the nurse expect?

Rationale

A. Place the client in a supine position: Placing a client supine is not necessary for restraint use and may increase the risk of aspiration, especially in a client with a PEG tube. Positioning should prioritize safety and comfort, typically semi-Fowler’s for feeding.

B. Remove the restraints every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, circulation, range of motion, and the client’s need for continued restraint. Regular release prevents complications such as skin breakdown, nerve injury, or impaired circulation.

C. Secure the straps with a square knot: Restraint straps should be secured using a quick-release knot, not a square knot, to allow rapid removal in an emergency. Using an incorrect knot can delay urgent intervention and compromise safety.

D. Attach the straps to the side rails of the bed frame: Restraints should be attached to the bed frame not the side rails that move, or another fixed point, to prevent injury. Attaching to movable side rails can cause entrapment or worsen injury if the rails are raised or lowered.

Rationale

A. Plan to meditate immediately after meals: Meditating immediately after eating may cause discomfort or drowsiness and can interfere with focus. It is recommended to meditate at a time when the client is alert and not experiencing postprandial fatigue, which supports effective stress reduction.

B. Tighten and relax muscles during relaxation therapy: Progressive muscle relaxation involves systematically tensing and then relaxing specific muscle groups to reduce physical tension and stress. This technique promotes awareness of muscle tightness and facilitates overall relaxation, making it an effective component of stress management.

C. Keep eyes open during relaxation therapy: Closing the eyes is typically recommended during meditation and relaxation exercises to minimize distractions and enhance focus. Keeping the eyes open can reduce the effectiveness of the therapy by increasing external stimuli and mental engagement.

D. Take short and shallow breaths when meditating: Effective meditation and relaxation techniques emphasize slow, deep, and controlled breathing. Short, shallow breaths can increase tension and limit oxygenation, reducing the calming effects of meditation. Deep breathing supports parasympathetic activation and stress reduction.