A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

"A provider can write a prescription for restraints 'as needed"."

"I should tie the restraints using a square knot."

"I need to tie the restraint to the part of the bed frame that moves."

"I will remove a client's restraints every 4 hours."

Answer and Explanation

The Correct Answer is B

Choice A Reason:
Restraints should never be prescribed on an "as needed" basis (PRN). Each application of restraints requires a specific and current provider order.
Choice B Reason:
Apply the appropriate restraint, using a clove hitch or a square knot. When applying restraints, using a square knot is essential to ensure that the restraints remain secure but can be easily removed in case of an emergency. A square knot provides a balance between security and quick release when needed.
Choice C Reason:
Restraints should be tied to a non-movable part of the bed frame, not to a part that moves, to prevent injury to the client.
Choice D Reason:
Restraints should be checked and removed more frequently, typically every 2 hours, to assess the client’s skin integrity and circulation, and to provide range-of-motion exercises.

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Correct Answer is ["A","B","E"]

Explanation

A.This is a clear breach of confidentiality as sharing client information with individuals who are not part of the healthcare team and without the client's consent violates patient privacy.

B.Discussing a client’s condition in a public area where unauthorized individuals (like visitors) can overhear is a breach of confidentiality. Patient information should be discussed in private settings to protect the client's privacy.

C.This action is a good practice to protect patient information and does not breach confidentiality.

D.This is acceptable as long as proper protocols are followed, such as using secure fax lines and confirming that the receiving party is authorized to receive the information. This action does not inherently breach confidentiality.

E.If the nurse is not involved in the care of all those clients and does not have a legitimate reason to access that information, this action can also be considered a breach of confidentiality. Healthcare providers should only access information relevant to their role and responsibilities.

A. A toddler who cries whenever their parent enters the examination room B. An adolescent who was admitted and refuses to speak to their parents C. A preschooler who was previously toilet trained and now requires diapers in the hospital D. A school-age child who has several abrasions on their lower legs

Correct Answer is D

Explanation

Choice A Reason:
A toddler who cries whenever their parent enters the examination room is incorrect. Toddlers may exhibit separation anxiety or fear of medical procedures, which is a common behavior in this age group.
Choice B Reason:
An adolescent who was admitted and refuses to speak to their parents is incorrect. Adolescents may exhibit behaviors such as withdrawal or reluctance to communicate with parents due to developmental changes, stress, or other factors unrelated to maltreatment.
Choice C Reason:
A preschooler who was previously toilet trained and now requires diapers in the hospital is incorrect. Regression in toileting skills is common in preschoolers during times of stress or illness, such as hospitalization. It does not necessarily indicate maltreatment but may be a response to the unfamiliar environment or medical condition.
Choice D Reason:
A school-age child who has several abrasions on their lower legs is correct. Abrasions on a school-age child's lower legs could potentially indicate physical abuse or neglect, especially if they are unexplained or inconsistent with the child's reported activities. Reporting such findings for further investigation is essential to ensure the safety and well-being of the child.

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A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A charge nurse is observing the staff on the unit. Which of the following situations should the charge nurse identify as a breach of confidentiality? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse working in an emergency department is caring for a group of clients. Which of the following clients should the nurse report for suspected maltreatment?

Correct Answer is D

Explanation

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A nurse is orienting a newly licensed nurse about the use of restraints. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

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