A patient has been admitted for surgery for a colostomy. The patient states, "I can't believe this has happened to me." What is the nurse's best response?

A) Anxiety: Anxiety is a subjective finding because it represents the client's perception of their emotional state. It is a feeling of unease, worry, or fear, which the client reports experiencing. Subjective findings are based on the client's self-report or feelings.

B) Alert: Being alert is an objective finding because it refers to the client's level of consciousness and responsiveness to stimuli. In this scenario, the nurse assesses that the client is alert based on their ability to respond appropriately to questions and stimuli in the environment.

C) Pacing: Pacing is an objective finding because it describes observable behavior. In this case, the nurse observes the client pacing in the room, which is a physical activity that can be seen or measured.

D) Restless: Restlessness is an objective finding because it describes observable behavior. The nurse assesses that the client appears restless based on their observed behavior of pacing in the room. Restlessness is a physical manifestation of the client's anxiety and is observable by others.

Answer: B. The padding of the restraints is against the client's bony prominences.

A. The nurse can insert one finger between the client's wrist and the restraint.
The proper guideline is that the nurse should be able to insert two fingers between the client's wrist and the restraint. This ensures the restraint is snug but not too tight, which helps prevent impaired circulation and skin breakdown.

B. The padding of the restraints is against the client's bony prominences.
This is the correct practice. The padding of the restraints should always be applied to protect the client’s skin and prevent injury, particularly over bony prominences where the risk of pressure sores or skin breakdown is higher.

C. The AP ties the straps of the restraints in a double knot.
A double knot should not be used because it can make it difficult to quickly release the restraint in an emergency. A quick-release knot should always be used to ensure the restraint can be removed easily and promptly if needed.

D. The AP ties the restraints to the side rails.
Restraints should never be tied to movable parts like side rails, as raising or lowering the side rails could cause injury. Restraints should be secured to a part of the bed frame that does not move to prevent harm to the client.