A nurse is caring for a client who is confused and has a prescription for wrist restraints. Which of the following actions should the nurse take?

​​​​​​​A. This is a sign of a lower motor neuron lesion which result in flaccid paralysis of the muscles on the same side of the lesion. This includes all muscles innervated by the facial nerve, including those controlling the eyebrows.
B. A positive Babinski sign, which is an important neurological examination finding, is identified when there is dorsiflexion of the big toe and fanning of the other toes in response to a stimulus. This reflex is normal in infants but should disappear by the age of 2 years. In adults, the presence of a positive Babinski sign typically indicates an underlying condition affecting the central nervous system, such as a brain or spinal cord injury.
C. A positive Chvostek's sign is an indication of neuromuscular irritability and is typically associated with conditions such as hypocalcemia. It is elicited by tapping the facial nerve in front of the ear, which, if positive, results in twitching of the facial muscles, particularly the mouth and periorbital muscles. In the context of hypomagnesemia, a positive Chvostek's sign may also be observed due to the role of magnesium in neuromuscular function and its interaction with calcium metabolism.
D. A positive Trousseau sign is a clinical indicator of hypocalcemia, which is characterized by carpopedal spasm that occurs when the blood flow to the arm is occluded. This can be elicited by inflating a blood pressure cuff on the patient's arm to a pressure higher than their systolic blood pressure and maintaining it for 2-3 minutes. The sign is considered positive if there is involuntary flexion of the wrist, thumb, and metacarpophalangeal joints, along with the extension of the fingers.

A. The best time for breast self-examination is usually about a week after the period starts when the breasts are less tender.

B. During perimenopause, menstrual cycles can become irregular; the client may not have regular periods until menopause.

C. Declining estrogen levels during perimenopause can indeed lead to various symptoms, including headaches, indicating the client understands the information.

D. Women should continue to receive Papanicolaou tests as recommended by their healthcare provider even after menopause, so this statement is incorrect.