A nurse is caring for a client who is restrained to each extremity. Which of the following assessments should the nurse perform first?

This is because chest percussion uses clapping of the chest using a cupped hand to vibrate the airways of the lungs and move and break apart the mucus inside the lungs.
Covering the area of percussion with a towel can help to reduce discomfort during the procedure.
Choice B is wrong because postural drainage should not be scheduled after meals.
It is best to schedule postural drainage before meals or at least 1-2 hours after meals to prevent discomfort or vomiting.

Choice Cis wrong because, during vibration, the client should inhale deeply and exhale slowly.
Choice Dis wrong because percussion should not be performed over the lower back.
It should be performed over the chest and back, avoiding areas such as the spine and breastbone.

This is because during the alarm reaction stage of general adaptation syndrome, which is also known as the fight-or-flight response, the sympathetic nervous system is activated by the sudden release of hormones.
This hormone release causes physical symptoms such as dilated pupils.
Choice A is wrong because depression is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Choice C is wrong because bradycardia, or a slow heart rate, is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Instead, an increase in heart rate is a common physical sign during this stage.
Choice D is wrong because physical exhaustion is not a manifestation that occurs during the alarm reaction stage of general adaptation syndrome.
Physical exhaustion occurs during the final stage of general adaptation syndrome, which is known as the exhaustion stage.