A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

The client has full range of motion in her wrist.

The client is attempting to remove the restraint.

The client has cyanotic digits.

The client denies discomfort.

Answer and Explanation

The Correct Answer is C

Choice A Reason:

The client has full range of motion in her wrist does not necessarily indicate a need to loosen the restraints. Full range of motion suggests that the restraints are not too tight and are allowing for some movement. However, it is important to regularly assess the client’s circulation, skin integrity, and comfort to ensure the restraints are not causing harm.

Choice B Reason:

The client is attempting to remove the restraint is a common behavior in clients who are restrained, especially if they are confused or agitated. While this behavior warrants close monitoring and possibly re-evaluating the need for restraints, it does not necessarily indicate that the restraints need to be loosened. The nurse should assess the client’s overall condition and consider alternative methods to ensure safety.

Choice C Reason:

The client has cyanotic digits is a critical finding that indicates impaired circulation. Cyanosis, or a bluish discoloration of the skin, occurs when there is a lack of oxygen in the blood. This can be a sign that the restraints are too tight and are restricting blood flow to the extremities. In this case, the nurse should immediately loosen the restraints to restore proper circulation and prevent further complications.

Choice D Reason:

The client denies discomfort is a positive finding, indicating that the client is not experiencing pain or distress from the restraints. However, the absence of discomfort does not rule out other potential issues such as impaired circulation or skin breakdown. Regular assessments are necessary to ensure the restraints are being used safely and effectively.

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Correct Answer is C

Explanation

Choice A Reason:

“I will keep spare crutch tips handy.” This statement is correct and indicates good practice. Keeping spare crutch tips handy ensures that the client can replace worn or damaged tips promptly, maintaining the safety and effectiveness of the crutches.

Choice B Reason:

“I will inspect my crutches every day for signs of wear.” This statement is also correct. Regular inspection of crutches for signs of wear and tear helps prevent accidents and ensures that the crutches remain in good working condition.

Choice C Reason:

“I will bear the weight of my body on my axillas.” This statement is incorrect and indicates that the client needs additional education. Bearing weight on the axillas (armpits) can cause nerve damage and discomfort. The correct technique is to support the body’s weight with the hands and arms, not the axillas.

Choice D Reason:

“I will support most of the weight of my body with my arms.” This statement is correct. Supporting the body’s weight with the arms and hands is the proper technique for using crutches, as it prevents nerve damage and ensures better control and stability.

A. Ask close-ended questions. B. Ask open-ended questions. C. Use directive questions. D. Use reflective questions.

Correct Answer is B

Explanation

Choice A Reason:

Ask close-ended questions is incorrect. Close-ended questions typically elicit short, specific responses such as “yes” or “no.” While they can be useful in certain situations, they do not provide enough information to thoroughly assess a client’s mental status. Open-ended questions allow the client to express themselves more fully, providing the nurse with better insight into their cognitive function.

Choice B Reason:

Ask open-ended questions is correct. Open-ended questions encourage the client to elaborate on their thoughts and feelings, which can reveal more about their mental status. This type of questioning helps the nurse assess the client’s orientation, memory, and thought processes more effectively.

Choice C Reason:

Use directive questions is incorrect. Directive questions are more structured and guide the client towards specific answers. While they can be useful for obtaining specific information, they do not allow for a comprehensive assessment of the client’s mental status.

Choice D Reason:

Use reflective questions is incorrect. Reflective questions are used to encourage the client to think more deeply about their responses and feelings. While they can be helpful in therapeutic settings, they are not the most effective for an initial assessment of mental status.

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A nurse is rounding on a client with bilateral wrist restraints. Which finding would warrant the nurse to loosen the restraints?

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