A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?
Document in the client's medical record every 15 min.
Offer toileting to the client every 4 hr.
Remove the restraint when the client falls asleep.
Request that the provider write an as-needed prescription for restraints.
The Correct Answer is A
A. Documenting in the client's medical record every 15 minutes is essential to monitor the client's status, including physical and psychological well-being, while in restraints. Accurate documentation ensures that any changes or responses to the intervention are recorded and communicated to other healthcare providers.
B. Offering toileting to the client every 4 hours may be necessary depending on the client's
individual needs, but it does not address the immediate need for monitoring the client's safety and well-being while restrained.
C. Removing the restraint when the client falls asleep is not appropriate without a healthcare provider's order. Restraints should only be removed based on a specific criteria set forth by
institutional policies or as directed by the healthcare provider.
D. Requesting an as-needed prescription for restraints is not appropriate. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a healthcare provider's assessment and orders.
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Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. Documenting urine color is essential after a transurethral resection of the prostate to monitor for bleeding and ensure that the bladder irrigation is effective in clearing out blood clots.
B. Monitoring for bladder spasms is important as they can indicate the presence of blood clots or other complications, and they can be very painful for the client.
C. Checking the drainage tubing for obstructions is crucial to maintain the patency of the catheter and ensure continuous irrigation. Obstructions can lead to complications such as bladder distention or increased bleeding.
D. Maintaining the client in a left side-lying position is not specifically required for continuous bladder irrigation and is not typically part of postoperative care for a client who had a transurethral resection of the prostate.
E. Using clean technique for intermittent irrigation is important to prevent infection. While sterile technique is ideal, clean technique can be used for the client's own catheter care at home or in settings where sterile technique is not feasible. However, in a clinical setting, sterile technique is usually preferred to minimize infection risk.
Correct Answer is C
Explanation
A. While reassurance is important, simply telling the client that she will adjust to changes to her body may minimize her concerns and not adequately address her emotional needs. It's important to offer support and provide resources to help the client cope with potential changes.
B. While an occupational therapist may be able to provide valuable support, their role may not specifically address the client's concerns about body image changes related to breast cancer treatment.
C. Reach to Recovery is a program offered by the American Cancer Society that connects newly diagnosed breast cancer patients with trained volunteers who have experienced breast cancer themselves. These volunteers can offer support, guidance, and practical tips for coping with the physical and emotional challenges of breast cancer diagnosis and treatment. Initiating a referral to this program can provide the client with valuable support from someone who has been through a similar experience.
D. While surgery may be an option for restoring the appearance of the breast, it may not fully address the client's concerns about potential changes to her body image. Additionally, not all breast cancer patients undergo surgery or choose reconstructive procedures, so it's important to provide support and resources regardless of the treatment chosen.
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