A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Assess skin temperature and color before applying the restraints.

Ensure that the client's bed is in the lowest position.

Secure restraints to allow three fingers to slide under the restraints.

Pad bony prominences before applying the restraints.

Attach the client's restraints to the bed rail.

Answer and Explanation

Correct Answer : A,B,C,D

When planning care for a client who has a prescription for extremity restraints on both wrists, the nurse should assess the client's skin temperature and color before applying the restraints to ensure that there is no circulation impairment. The nurse should also ensure that the client's bed is in the lowest position to prevent falls. The restraints should be secured to allow three fingers to slide under them to prevent injury and ensure proper circulation. Bony prominences should be padded before applying the restraints to prevent pressure injuries.

Option e is incorrect because attaching the client's restraints to the bed rail can cause injury if the bed rail is moved or adjusted.

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Correct Answer is A

Explanation

As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and ﬂexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.

Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be inﬂuenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.

In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.

A. A client who requires teaching prior to discharge. B. A client who is watching a video about the meal services at the facility in their primary language. C. A client who is learning to use an incentive spirometer and has an interpreter present. D. A client who requires administration of a prescribed pain medication.

Correct Answer is A

Explanation

The nurse should provide written materials in the client's primary language for a client who requires teaching prior to discharge. This ensures that the client has access to important information in a language they understand and can refer to after leaving the facility.

b. A client who is watching a video about meal services in their primary language may not require additional written materials.

c. A client who is learning to use an incentive spirometer with the help of an interpreter may not require additional written materials.

d. The administration of a prescribed pain medication does not necessarily require the provision of written materials.

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A nurse is planning care for a client who has a prescription for extremity restraints on both wrists. Which of the following actions should the nurse include in the plan of care? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an older adult client. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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