A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

Obtain a prescription for restraints from the provider.

Document the indications for using wrist restraints.

Explain the procedure to the client and their family.

Attempt less restrictive alternatives.

Answer and Explanation

The Correct Answer is D

A.   While a prescription may be necessary, attempting less restrictive alternatives should be the first action.
B.   Documentation is important but should not precede attempting less restrictive alternatives.
C.   Education about the use of restraints is important but should follow attempts at less restrictive alternatives.
D.   The nurse should exhaust all possible alternatives to restraints before considering their use, in line with the principle of least restrictive intervention.

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Correct Answer is D

Explanation

A. This action may increase the risk of injury to both the nurse and the client.

B. This action does not effectively prevent the fall or minimize injury.

C. Moving quickly to a position in front of the client can cause imbalance and increase the risk for falling.
D. Allowing the client to slide down their outstretched leg can help prevent injury to both the client and the nurse.

A. "I do not have to worry about using protection now that I am in menopause." B. use lubricants to help prevent pain during sex." C. 1 feel more self-conscious with how I look now that I am older." D. "I still think about having sex at my age?

Correct Answer is A

Explanation

A. This statement reflects a misconception about menopause and sexual health, indicating a need for education on safe sex practices.
B. This statement indicates the client is taking steps to address discomfort during sexual activity, which is appropriate.
C. This statement reflects body image concerns commonly experienced by older adults and may warrant further exploration but does not necessarily indicate a need for immediate intervention.
D. This statement indicates a normal interest in sexual activity and does not necessarily indicate a need for intervention.

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A nurse is considering placing wrist restraints on a client who has cognitive deficits and has pulled out their IV catheter. Before using wrist restraints, which of the following actions must the nurse take first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is ambulating a client who is unsteady. The client begins to fall. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?

Correct Answer is A

Explanation

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