A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.
Which of the following actions by the AP requires intervention by the nurse?

Using a quick-release tie to secure the restraint.

Tying the restraint to the bed frame.

Placing the restraint across the client's chest.

Applying the restraint over the client's gown.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Using a quick-release tie to secure the restraint is standard practice as it ensures the restraint can be removed quickly in case of an emergency, ensuring patient safety.

Choice B rationale

Tying the restraint to the bed frame is appropriate because it prevents the client from removing the restraint independently while still allowing for quick-release if necessary. It ensures the client's safety by securing the restraint to a stable part of the bed.

Choice C rationale

Placing the restraint across the client's chest requires intervention because it can restrict breathing and cause serious harm. This practice is unsafe and contraindicated in restraint use guidelines.

Choice D rationale

Applying the restraint over the client's gown is correct as it provides a barrier between the skin and the restraint, reducing the risk of skin irritation or injury.

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Correct Answer is C

Explanation

Choice A rationale

A repressed grief response, where an individual avoids expressing their grief, is considered delayed grief, not exaggerated grief. This can manifest as physical symptoms or psychological issues later on.

Choice B rationale

Grief that begins following a terminal diagnosis is anticipatory grief, which is a normal response as individuals begin to process the impending loss. It prepares them emotionally for the eventual death.

Choice C rationale

Exaggerated grief involves intense, prolonged, and often harmful reactions such as self-destructive behaviors. This type of grief can significantly impair a person's ability to function and may require professional intervention.

Choice D rationale

A grief response triggered by a secondary loss (e.g., loss of job or home) is known as cumulative grief. While it complicates the grieving process, it does not inherently lead to the exaggerated, self-destructive behaviors seen in exaggerated grief.

A. Suggest that the family member contact a grief counselor. B. Describe a personal experience with the death of a family member. C. Include the family member in providing care for the client. D. Ask if they have had prior experience with the death of a family member.

Correct Answer is C

Explanation

Choice A rationale

Suggesting that the family member contact a grief counselor may be helpful, but it does not address their immediate need to help. Involving the family member in care can provide emotional support and a sense of purpose.

Choice B rationale

Describing a personal experience with the death of a family member may offer empathy but can shift the focus away from the client's needs. It is essential to keep the conversation centered on the family member's desire to help.

Choice C rationale

Including the family member in providing care for the client is an appropriate action. It allows them to participate actively, provides emotional support, and can be comforting for both the client and the family member.

Choice D rationale

Asking if the family member has had prior experience with the death of a family member may be relevant but does not directly address their desire to help. It is more effective to involve them in the care process immediately. .

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A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.Which of the following actions by the AP requires intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is C

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A nurse is observing an assistive personnel (AP) apply a belt restraint to a client.
Which of the following actions by the AP requires intervention by the nurse?