A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

"Remove clocks from the client's room."

"Check on the client frequently while he is in the restroom."

"Encourage physical activity throughout the day to expend energy."

"Use full-length side rails on the client's bed."

Answer and Explanation

The Correct Answer is C

A. "Remove clocks from the client's room." –
Removing clocks can increase confusion and disorientation. Instead, having a visible clock and calendar can help the client stay oriented.
B. "Check on the client frequently while he is in the restroom." –
While frequent monitoring is important, excessive surveillance may increase agitation and distress. A better alternative is to ensure the restroom is safe and accessible.
C. "Encourage physical activity throughout the day to expend energy." –
Engaging the client in physical activity helps reduce restlessness, promotes better sleep, and decreases the likelihood of agitation, which can reduce the need for restraints.
D. "Use full-length side rails on the client's bed." –
Full-length side rails can be considered a form of restraint as they may limit movement and increase the risk of falls or injury if the client tries to climb over them.

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Correct Answer is A

Explanation

A. "Arrange to perform all nonessential tasks for the client at one time."
Grouping nonessential tasks reduces frequent disruptions, allowing the client to rest more effectively, which is essential for recovery.
B. "Encourage the client to sleep as much as possible during the day."
Excessive daytime sleeping can disrupt the client’s sleep-wake cycle, leading to difficulty sleeping at night.
C. "Perform routine hygiene for the client during the night."
Performing hygiene tasks at night can disturb the client’s rest and impact recovery.
D. "Remove limits on visiting hours for the client." Unrestricted visiting hours can increase noise and interruptions, making it harder for the client to get adequate rest.

A. "The food is not great, but it is nice not having to do all of my own cooking." B. "When I go out, I've been using public transportation since I can't drive anymore." C. "I don't want to go to the activity room because none of the other residents can hear." D. "The staff sometimes have to remind me to use a cane when I walk in the hall."

Correct Answer is C

Explanation

A. "The food is not great, but it is nice not having to do all of my own cooking." This statement shows acceptance by acknowledging both the challenges and benefits of the transition.
B. "When I go out, I've been using public transportation since I can't drive anymore." This reflects adaptation to the changes by finding alternative transportation.
C. "I don't want to go to the activity room because none of the other residents can hear." This suggests social withdrawal and frustration, which may indicate difficulty accepting the transition to assisted living.
D. "The staff sometimes have to remind me to use a cane when I walk in the hall." This shows acceptance of help from staff, which suggests an adjustment to the new environment rather than resistance.

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A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the staff nurse include?

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