A nurse is reinforcing teaching about foot care with a client who has type 2 diabetes mellitus.
Which of the following statements by the client indicates an understanding of the teaching?

The correct answer is a. Plan to remove the restraints as soon as the client is calm.

Choice A reason: The primary goal after applying restraints is to ensure the safety of the client and others. Once the client is calm, planning for the removal of restraints is essential to maintain the client’s dignity and to adhere to ethical standards of minimizing restraint use.

Choice B reason: While offering snacks is part of general care, it is not specifically related to the immediate action required following the application of restraints. Nutritional needs should be addressed, but they do not take precedence over the assessment and potential removal of restraints.

Choice C reason: Ensuring that a prescription for restraints is signed within 48 hours is a legal requirement, but it is not the immediate action to be taken following the application of restraints. The focus should be on the client’s current state and reassessing the need for continued restraint.

Choice D reason: Monitoring the client’s range of motion every 60 minutes is important to prevent complications from restraint, such as contractures or muscle atrophy. However, this is secondary to the immediate reassessment of the need for restraint and planning for its removal as soon as the client is calm.

Choice A rationale:

Bradycardia. Heparin is an anticoagulant medication that primarily affects the blood's clotting ability. Bradycardia, or a slow heart rate, is not a common side effect of heparin. Therefore, it is not a typical adverse effect to report in this context.

Choice B rationale:

Anorexia. Anorexia, or a loss of appetite, is not a common adverse effect of heparin. Heparin's primary mode of action is to prevent blood clot formation, and it does not directly affect appetite.

Choice C rationale:

Weight gain. Weight gain is not a typical adverse effect of heparin. Heparin's mechanism of action does not lead to changes in body weight. Weight gain could be related to other factors but is not directly associated with heparin administration.

Choice D rationale:

Epistaxis. Epistaxis, or nosebleeds, can be a sign of a bleeding disorder or an adverse effect of anticoagulant therapy like heparin. Heparin can increase the risk of bleeding, including nosebleeds, and should be monitored closely for this adverse effect. It is important to report any signs of excessive bleeding to the healthcare provider as they may need to adjust the dosage or monitor the patient more closely.