A nurse is considering the use of restraints. The nurse should:
Ensure that the patient has been adequately monitored.
Proceed with the application of restraints.
Explore alternative interventions to address the patient’s behavior.
Obtain verbal consent from the patient’s family.
The Correct Answer is C
Choice A rationale
Ensuring that the patient has been adequately monitored is important, but it is not the first step when considering the use of restraints. The nurse should first explore alternative interventions.
Choice B rationale
Proceeding with the application of restraints without considering alternatives can lead to unnecessary use of restraints, which can cause physical and psychological harm to the patient.
Choice C rationale
Exploring alternative interventions to address the patient’s behavior is the first step. Restraints should only be used as a last resort when other interventions have failed.
Choice D rationale
Obtaining verbal consent from the patient’s family is important, but it is not the first step. The nurse should first explore alternative interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Poor balance and muscle weakness are significant risk factors for falls among older adults. These conditions can make it difficult for individuals to maintain stability and recover from a loss of balance, increasing the likelihood of falls.
Choice B rationale
Vision impairment is a well-known risk factor for falls. Poor vision can make it difficult for individuals to see obstacles and navigate their environment safely, leading to an increased risk of falls.
Choice C rationale
Medications that cause dizziness are a common risk factor for falls. Many medications, including those for blood pressure, pain, and anxiety, can have side effects that affect balance and coordination, increasing the risk of falls.
Choice D rationale
Regular physical activity is not a risk factor for falls. In fact, regular exercise can improve strength, balance, and coordination, reducing the risk of falls. Physical activity is often recommended as a preventive measure to help older adults maintain their mobility and independence.
Correct Answer is C
Explanation
Choice A rationale
A 5-year-old patient admitted yesterday with pneumonia may require frequent assessments and interventions that are within the scope of practice for an LPN. However, the complexity of care for a newly admitted patient with a potentially unstable condition may be better suited for an RN.
Choice B rationale
A 78-year-old female with osteoporosis who needs assistance performing range of motion exercises and ambulating with a walker can be managed by an LPN. These tasks are within the LPN’s scope of practice and do not require the higher level of assessment and decision-making skills of an RN.
Choice C rationale
A 78-year-old patient newly admitted with congestive heart failure requires complex assessments, monitoring, and interventions that are within the scope of practice for an RN. The RN’s advanced skills and knowledge are necessary to manage the patient’s condition effectively.
Choice D rationale
A 34-year-old patient post knee arthroscopy who requires reinforced crutch walking can be managed by an LPN. These tasks are within the LPN’s scope of practice and do not require the higher level of assessment and decision-making skills of an RN.
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