The nurse is caring for a patient who is confused and agitated. The patient continues to get out of bed without assistance and is at high risk for falls. The nurse is considering alternatives to implement prior to applying restraints.

Of the following, which would the nurse NOT consider in the plan of care as an alternative to restraints?

Give the patient something to do while in bed, such as a coloring book or puzzle.

Play music or video selections of the patient's choice.

Place all 4 side rails up to prevent the patient from getting out of bed and falling.

Reduce stimulation noise, and light to calm the patient.

Answer and Explanation

The Correct Answer is C

The correct answer is choice C, Place all 4 side rails up to prevent the patient from getting out of bed and falling.

When considering alternatives to restraints for a confused and agitated patient who is at high risk for falls, placing all 4 side rails up to prevent the patient from getting out of bed and falling is not an appropriate alternative. This action can be considered as restraint use and can increase the patient's agitation and risk for injury. Instead, the nurse should provide the patient with activities to do while in bed, play music or video selections of the patient's choice, and reduce stimulation noise and light to calm the patient.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

The correct answer is choice D. Identify the five major drug side effects before discharge tomorrow. A measurable client goal should be specific, observable, and

measurable. It should describe a behavior or outcome that the client can achieve. Identifying the five major drug side effects is specific and measurable. Sitting out of bed in a chair is too general, while verbalizing feelings about surgery at some point is not observable and not time-bound. Eating low sodium food is specific but not measurable.

A. 2+ Pitting Edema B. 3+ Pitting Edema C. 1+ Non-Pitting Edema D. 4+ Pitting Edema

Correct Answer is D

Explanation

A. 2+ Pitting Edema:This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.

B. 3+ Pitting Edema:This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.

C. 1+ Non-Pitting Edema:This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.

D. 4+ Pitting Edema:4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is the best example of a measurable client goal? The client will:

Correct Answer is D

Explanation

A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?

Correct Answer is D

Explanation

A nurse is providing education to a client diagnosed with insomnia. What sleeppromoting techniques would the nurse suggest to help the client's condition? Select all that apply.

The nurse is performing a head-to-toe assessment on a patient. The nurse uses their thumb and first finger to lift or pinch a fold of skin under the clavicle to check for skin turgor. Which of the following findings would be considered normal for this assessment?

A home care nurse is caring for a comatose patient who requires total care. A visitor stops by the house identifying as a family friend and inquires about the patient's condition and if there is anything they can do to help the family. How should the nurse respond to maintain HIPAA compliance?

While caring for a female patient with advanced multiple sclerosis, the nurse is discussing the difference between hospice and palliative care. Which statement by the patient indicates understanding of the difference between hospice care and palliative care?

Which of the following is the best example of a measurable client goal? The clientwill:

A nurse is using the SOAP documentation format to chart on their patient in a systematic and organized way. When using SOAP, what sections would be present in the charting? Select all that apply.

Exhibits A nurse needs to calculate the amount of a medication based on a patient's weight in kg. If the patient weighs 130 pounds, how many kg does the patient weigh? Round to the nearest tenth.

A client has just had abdominal surgery, and the nurse is consulting with him about his diet now that he is allowed to eat. Which nutrient is most important for wound healing?