A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

Check that the restraint is tied to a fixed frame of the bed.

Pad bony prominences on the wrist.

Remove the restraint every 4 hr to allow movement.

Tie the restraint with a knot that will tighten when pulled.

Answer and Explanation

The Correct Answer is B

A.   Check that the restraint is tied to a fixed frame of the bed: Restraints should never be tied to the side rails or a fixed frame of the bed, as this can lead to serious injuries. Restraints should be secured to the bed frame using quick-release ties to ensure safety.
B.   Pad bony prominences on the wrist: Correct. Padding bony prominences on the wrist is an important step in the use of restraints to prevent skin breakdown and pressure injuries.
C.   Remove the restraint every 4 hr to allow movement: While repositioning and releasing restraints periodically is essential for the client's comfort and safety, it is not appropriate to remove wrist restraints entirely every 4 hours, as they were prescribed for a specific purpose.
D.   Tie the restraint with a knot that will tighten when pulled: Restraints should never be tied with a knot that can tighten when pulled, as this can cause harm to the client and restrict blood flow. Restraints should be secured using quick-release ties to allow for easy removal in
emergencies.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. The reduced muscle tone had relaxed the law muscles CORRECT
Prior to death, decreased muscle tone causes jaw muscles to relax resulting in an open mouth.

B. "That happens when a person gets close to death INCORRECT
This automatic response is nontherapeutic and does not address the family member's question

C. "I can apply a chin strap to help hold the mouth closed INCORRECT
Applying a chin strap is a postmortem action that the nurse can take to keep the mouth closed

A. Precontemplation B. Preparation

Correct Answer is A

Explanation

A. Precontemplation
According to evidence-based practice, the nurse should identify that precontemplation is the first stage the client will experience when using the stages of health behavior change. In this stage,
the client avoids discussing the behavior and does not intend to make a change in behavior. The stages of health behavior change are pre contemplation, contemplation, preparation, action and the maintenance stage

B. Preparation INCORRECT
The nurse should identify that preparation is the third stage the client will experience when using the stages of health behavior change. In this stage, the client plans to make minor changes to behavior. However, according to evidence-based practice, another stage occurs prior to the preparation stage.

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A nurse is contributing to a plan of care for a client who has a new prescription for a wrist restraint. Which of the following actions should the nurse include in the plan?

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