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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
“I can apply lotion to soften calluses as long as I don’t put lotion between my toes.” This is because moisturizing can help keep skin soft and prevent corns and calluses from forming.
However, it is important to avoid putting lotion between the toes as this can increase the risk of infection 1.
Choice A is wrong because soaking feet in warm water daily can soften corns and calluses, making it easier to remove the thickened skin 2.
Choice B is wrong because while using corn pads can help protect the area where corn has formed, it is important to follow the manufacturer’s instructions for use and removal.
Choice C is wrong because using over-the-counter liquid medication to remove corn is not recommended for people with diabetes.
Correct Answer is A
Explanation
According to self-efficacy theory, learning develops from multiple sources, including perceptions of one’s past performance, vicarious experiences, performance feedback, affective/physiological states, and social influences.
Choice B is wrong because simply explaining the need for education to the client may not necessarily increase their motivation to learn.
Choice C is wrong because seeking family approval by agreeing to a teaching plan may not necessarily increase the client’s motivation to learn.
Choice D is wrong because the nurse’s empathy about the client having to self-inject may not necessarily increase their motivation to learn.
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