Which assessment finding would be considered normal in an elderly client?

This is because restraints should only be used as a last resort when other alternatives have failed to ensure the patient’s safety and when there is a valid order from the primary healthcare provider.

Assessing the need for restraints placement involves evaluating the patient’s condition, behavior, risk factors, and potential benefits and harms of using restraints.

Choice A is wrong because visual inspection of skin for placement is done after applying restraints, not before.

This is to check for any signs of injury, irritation, or circulation impairment caused by the restraints.

Choice B is wrong because positioning for proper body alignment is done during and after applying restraints, not before.

This is to prevent complications such as pressure ulcers, contractures, or nerve damage due to improper positioning.

Choice D is wrong because reviewing facility policy before usage is not a nursing intervention, but a legal and ethical requirement.

Nurses should be familiar with the facility policy and guidelines regarding the use of restraints and follow them accordingly.

However, this does not replace the need for individualized assessment and evaluation of each patient’s situation.

These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.

Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.

These nursing interventions can help promote bowel movement and prevent constipation. According to, constipation is a common gastrointestinal symptom caused by various factors such as a low-fiber diet, inadequate fluid intake, decreased gastrointestinal motility, medication use, and insufficient activity.

Therefore, encouraging high-fiber food choices, increasing fluid intake to 2,000 mL per day, and encouraging ambulation several times daily are appropriate interventions to address these factors and improve bowel function.

Choice D is wrong because administering antacids as necessary per the bowel management program is not a nursing intervention for constipation.

Antacids are used to neutralize stomach acid and relieve heartburn or indigestion.

They do not have any effect on bowel movement or constipation. In fact, some antacids may cause constipation as a side effect.

Therefore, this intervention is not relevant to the plan of care for a client diagnosed with constipation.