A nurse is teaching a newly licensed nurse about the use of restraints for adult clients. Which of the following information should the nurse include in the teaching?
The nurse should document observation of the client every 15 min.
The provider should assess the client 48 hr after the restraint is applied.
The prescription for a restraint should be renewed by the provider 6 hr after application.
The nurse should assist the client with range-of-motion exercises every 12 hr after restraint application.
The Correct Answer is A
Choice A reason: Documenting observation every 15 min is correct. Frequent monitoring ensures client safety, assesses circulation, skin integrity, and psychological well-being, and prevents complications such as injury or restricted blood flow.
Choice B reason: The provider should assess the client much sooner than 48 hr. Restraint use requires frequent reassessment, typically within 24 hr, to determine ongoing necessity. Waiting 48 hr is unsafe.
Choice C reason: The prescription for a restraint should be renewed every 24 hr, not 6 hr. Restraints require daily provider review to ensure they remain necessary and appropriate.
Choice D reason: Range-of-motion exercises should be performed every 2 hr, not every 12 hr. Frequent ROM prevents contractures, maintains circulation, and reduces complications from immobility.
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Related Questions
Correct Answer is A
Explanation
Choice A reason: Reporting suspected abuse to Adult Protective Services is the nurse’s legal and ethical responsibility. Visible contusions on all extremities raise concern for physical abuse, and mandatory reporting laws require healthcare providers to notify protective services to ensure client safety. This is the correct action.
Choice B reason: Interviewing the client with the adult child present is inappropriate because it may prevent the client from speaking honestly about the situation. The presence of a potential abuser can inhibit disclosure and compromise assessment accuracy.
Choice C reason: Telling the client they must answer every Question is coercive and violates patient autonomy. Clients have the right to refuse to answer questions, and forcing responses is non-therapeutic.
Choice D reason: Advising the client to consult a social worker is supportive but insufficient. While social workers provide resources and counseling, the priority action is mandatory reporting to ensure immediate safety.
Correct Answer is A
Explanation
Choice A reason: Hallucinations are a common manifestation of delirium, especially when triggered by acute illness such as fever. Delirium is characterized by disturbances in attention, awareness, and cognition, often accompanied by perceptual disturbances like visual or auditory hallucinations.
Choice B reason: Agnosia, the inability to recognize objects or people, is more commonly associated with neurocognitive disorders such as dementia rather than acute delirium. While delirium affects cognition, agnosia is not a typical finding.
Choice C reason: Bradycardia is not a hallmark of delirium. Delirium is primarily a cognitive and perceptual disturbance, not a cardiac rhythm disorder. Bradycardia would suggest another underlying medical issue.
Choice D reason: Aphasia, a language disturbance, is more characteristic of stroke or other focal neurological disorders. Delirium may cause disorganized speech due to confusion, but not true aphasia.
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