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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
Choice A Reason:
"Clients who participate in research studies forfeit their HIPAA right to privacy. "This statement is incorrect. While research studies may involve the use of personal health information, participants still retain their HIPAA rights to privacy. Research institutions are required to follow strict guidelines for protecting participants' privacy and confidentiality.
Choice B Reason:
"HIPAA prohibits the uploading of photographs of client's providers to social media sites. "This statement is true. HIPAA prohibits the unauthorized disclosure of protected health information (PHI), which includes photographs, on social media or any other public platform without the patient's explicit consent.
Choice C Reason:
"HIPAA allows facility-specific coding of client health care information to ensure privacy." This statement is ambiguous and could be interpreted in different ways. HIPAA requires covered entities to implement safeguards to protect the privacy of health information, which may include coding or encryption of data. However, facility-specific coding alone may not be sufficient to ensure privacy compliance without proper implementation of HIPAA privacy and security standards.
Choice D Reason:
"HIPAA allows clients to request a review of their own medical records. “This statement is correct. HIPAA grants individuals the right to access and review their own medical records held by covered entities, such as healthcare providers and health plans. This access allows patients to verify the accuracy of their medical information and understand how their health information is being used and disclosed.
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