When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?

Tie the restraints to the side rail.

Remove the restraints every 3 hr.

Remove one restraint at a time.

Secure restraints with a square knot.

Answer and Explanation

The Correct Answer is C

When caring for a client who has wrist restraints after an episode of violent behavior, the nurse should remove one restraint at a time.
This allows the nurse to assess the client’s behavior and response to having one arm free while still maintaining some level of control and safety.
Choice A is wrong because tying the restraints to the side rail can be dangerous as it can cause injury to the client if they move suddenly.
Choice B is wrong because removing the restraints every 3 hours is not a specific guideline and may vary depending on the facility’s policy and the client’s condition.
Choice D is wrong because securing restraints with a square knot can make it difficult to quickly release the restraints in an emergency.

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Correct Answer is C

Explanation

As people age, they may experience a decrease in their sense of balance. This can increase the risk of falls and injuries.
Choice A is wrong because older adults may actually have a decreased sense of pain.
Choice B is wrong because older adults may experience changes in their sleep patterns, including difficulty falling asleep or staying asleep.
Choice D is wrong because while urinary incontinence can be a common issue among older adults, it is not limited to nighttime.

A. "Hold your breath when performing the exercises.". B. "Contract your pelvic muscle when performing the exercises.". C. "Tighten your buttocks when performing the exercises.". D. "Expect improvement after 2 weeks of performing the exercises.".

Correct Answer is B

Explanation

“Contract your pelvic muscle when performing the exercises.” Kegel exercises strengthen the pelvic floor muscles, which support the uterus, bladder, small intestine, and rectum.
To do Kegels correctly, you need to contract and relax your pelvic floor muscles.
Choice A is wrong because you should avoid holding your breath while doing Kegel exercises.
Instead, breathe freely during the exercises.
Choice C is wrong because you should focus on tightening only your pelvic floor muscles and be careful not to flex the muscles in your buttocks.
Choice D is wrong because it takes time to strengthen pelvic floor muscles.
You should aim for at least three sets of 10 to 15 repetitions a day and give it 3 to 6 weeks before expecting improvement12.

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When caring for a client who has wrist restraints after an episode of violent behavior, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What findings should the nurse expect when assessing an older adult client?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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