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

Elimination needs

Comfort level

Skin integrity

Peripheral pulses.

Answer and Explanation

The Correct Answer is D

When a client is restrained to each extremity, it is important for the nurse to assess the client’s peripheral pulses first to ensure that circulation is not compromised.

Choice A, Elimination needs, is important but not the first priority in this situation.

Choice B, Comfort level, is also important but not the first priority in this situation.

Choice C, Skin integrity, is important but not the first priority in this situation.

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Correct Answer is A

Explanation

According to self-efficacy theory, learning develops from multiple sources, including perceptions of one’s past performance, vicarious experiences, performance feedback, affective/physiological states, and social influences.
Choice B is wrong because simply explaining the need for education to the client may not necessarily increase their motivation to learn.
Choice C is wrong because seeking family approval by agreeing to a teaching plan may not necessarily increase the client’s motivation to learn.
Choice D is wrong because the nurse’s empathy about the client having to self-inject may not necessarily increase their motivation to learn.

A. "Delirium does not affect a client's perception of her environment.". B. "Delirium has a slow progression.". C. "Delirium does not affect a client's sleep cycle.". D. "Delirium has an abrupt onset.".

Correct Answer is D

Explanation

“Delirium has an abrupt onset.” Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of someone’s surroundings.
The disorder usually comes on fast — within hours or a few days.

Choice A is wrong because delirium does affect a client’s perception of her environment.
Choice B is wrong because delirium does not have a slow progression, but rather an abrupt onset.
Choice C is wrong because delirium can affect a client’s sleep cycle.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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