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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

Choice A rationale
Keeping the fluorescent ceiling light on at night can cause glare and disrupt sleep, which is not ideal for safety. It may also create shadows that can be disorienting.
Choice B rationale
Keeping the walker at the end of the bed is not practical. The walker should be within easy reach to ensure the client can use it immediately upon getting out of bed.
Choice C rationale
Placing grip bars in the shower is a correct and effective safety measure. Grip bars provide stability and support, reducing the risk of falls while bathing.
Choice D rationale
Placing an area rug at the entry of the bathroom can be a tripping hazard. Rugs can slip or bunch up, increasing the risk of falls.

A. A newly admitted client with a seizure disorder. B. A post-op laparotomy client who is waiting for discharge instructions. C. A client who needs assistance with feeding. D. A dehydrated client with an electrolyte imbalance.

Correct Answer is C

Explanation

Choice A rationale
A newly admitted client with a seizure disorder requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.
Choice B rationale
A post-op laparotomy client who is waiting for discharge instructions requires specific education and assessment, which is beyond the scope of practice for a nursing assistant.
Choice C rationale
A client who needs assistance with feeding is the correct answer. Assisting with feeding is within the scope of practice for a nursing assistant.
Choice D rationale
A dehydrated client with an electrolyte imbalance requires close monitoring and assessment, which is beyond the scope of practice for a nursing assistant.

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A nurse is considering the use of restraints. The nurse should:

Nursing Test Bank

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