When using wrist restraints, which of these statements is correct?

Apply them safely and secure to the bed rails.

Use to protect elderly patients from pulling out tubes and lines as soon as you place them.

Apply them to clients who have a history of violence or a previous fall for everyone’s protection.

Use them only as a last resort after attempting alternatives and get an order to do so.

Answer and Explanation

The Correct Answer is D

Use them only as a last resort after attempting alternatives and get an order to do so. This is because restraints are used to protect persons from harming themselves or others, but they can also cause injuries, falls, and death. Therefore, they should be used only when less restrictive measures fail to protect the person or others, and only with informed consent and a doctor’s order.

Choice A is wrong because restraints should not be secured to the bed rails, but to the movable part of the bed frame out of the person’s reach.

This prevents the person from getting entangled or injured by the restraints.

Choice B is wrong because restraints should not be used for staff convenience or to control or prevent a behavior. They should be used only for the immediate physical safety of the person or others.

Choice C is wrong because restraints should not be applied to clients who have a history of violence or a previous fall for everyone’s protection. They should be used only when there is a clear and present danger of harm to the person or others.

Normal ranges for restraints are:

Check the person at least every 15 minutes
Remove restraints and meet basic needs at least every 2 hours
Apply restraints so that they are snug but allow enough room to fit one finger between the restraint and the wrist

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Correct Answer is B

Explanation

This is the appropriate action because it prevents the spread of infection and maintains a clean environment.

The nurse should also wear gloves and dispose of the bag properly.

Choice A is wrong because saturating the dressing with saline before removing it can cause maceration of the skin and increase the risk of infection. The dressing should be removed gently and carefully, and if it is adhered to the wound, small amounts of sterile saline can be used to loosen it.

Choice C is wrong because using the old dressing to debride any tissue that is adhered to the wound can cause trauma, bleeding, and pain. The nurse should use sterile forceps or cotton- tipped applicators to gently press moistened gauze into the wound surfaces.

Choice D is wrong because reinserting the drain if removed with the dressing can cause injury and infection. The nurse should notify the surgeon immediately if the drain is accidentally removed.

A. Mood disorder. B. Sensory deprivation. C. Anxiety. D. Cerebral vascular accident (CVA).

Correct Answer is B

Explanation

Sensory deprivation is a condition in which a person experiences a lack of sensory input or stimulation.

This can result from isolation, confinement, or loss of sensory function. Sensory deprivation can cause psychological and physiological changes, such as irritability, confusion, paranoia, hallucinations, depression, anxiety, and cognitive impairment.

Choice A is wrong because mood disorder is a general term for a group of mental health conditions that affect a person’s emotional state, such as depression, bipolar disorder, or anxiety disorder. Mood disorder is not likely to be caused by isolation precautions for C diff.

Choice C is wrong because anxiety is a feeling of nervousness, worry, or fear that interferes with daily functioning. Anxiety can be triggered by stress, trauma, or other factors, but it is not a direct consequence of isolation precautions for C diff.

Choice D is wrong because cerebral vascular accident (CVA), also known as stroke, is a sudden interruption of blood flow to the brain that causes neurological damage. CVA can cause symptoms such as weakness, numbness, slurred speech, vision loss, or confusion, but it is not related to isolation precautions for C diff.

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When using wrist restraints, which of these statements is correct?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which action is appropriate for a nurse to remove a soiled wound dressing?

Correct Answer is B

Explanation

An 82-year-old client was admitted to the hospital on isolation precautions 3 days ago for C diff. The client begins to demonstrate irritability, confusion, and paranoia. Which of the following is the best reason for the assessment findings?

Correct Answer is B

Explanation

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