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."
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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Related Questions
Correct Answer is D
Explanation
A. "Intensity of pain levels decrease as people age."
Pain perception does not necessarily decrease with age. Older adults experience pain similarly to younger individuals, but they may express it differently.
B. "The client is less likely to respond to analgesics." Older adults respond to analgesics, but they may be more sensitive to certain medications due to age-related physiological changes. Appropriate dosing and monitoring are essential.
C. "Pain is an expected finding for an older adult." Pain is not a normal part of aging. While some chronic conditions associated with aging can cause pain, it should always be assessed and treated appropriately.
D. "The client may under-report their pain intensity."
Older adults may under-report pain due to factors such as fear of being a burden, belief that pain is a normal part of aging, or concerns about medication side effects. Nurses should use appropriate pain assessment tools to evaluate and address their pain effectively.
Correct Answer is B
Explanation
A. "Speech therapist" –
A speech therapist helps clients with swallowing difficulties (dysphagia) and communication impairments but does not focus on activities of daily living (ADLs) like dressing and toileting.
B. "Occupational therapist" –
An occupational therapist assists clients in regaining independence with ADLs, such as dressing, toileting, and bathing, by teaching adaptive techniques and recommending assistive devices.
C. "Physical therapist" –
A physical therapist focuses on improving mobility, strength, and balance but does not specifically address dressing and toileting tasks.
D. "Recreational therapist" –
A recreational therapist works on improving the client’s quality of life through leisure activities and social engagement, not basic self-care tasks.
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