Which of the following is essential when restraints are applied to a client?

Use a square knot.

Assess the extremity for circulation and neurological integrity every 2 hours.

Secure the restraint to the side rail.

Assess restraints and skin integrity every 12 hours.

Answer and Explanation

The Correct Answer is B

A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.

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Correct Answer is C

Explanation

A. Bronchial airway constriction: During the fight-or-flight response, bronchial airways typically dilate to increase airflow to the lungs, not constrict.
B. Hypoglycemia: The fight-or-flight response typically increases blood glucose levels to provide quick energy, leading to hyperglycemia rather than hypoglycemia.
C. Dilated pupils: Pupils dilate during the fight-or-flight response to enhance vision and perception of potential threats. This is a correct manifestation of the stress response.
D. Decreased blood pressure: The fight-or-flight response usually causes an increase in blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.

A. Being a victim of a crime B. Motor vehicle accident C. Living in poverty D. Loss of a loved one

Correct Answer is C

Explanation

A. Being a victim of a crime: This is typically considered an acute stressor as it represents a single, intense event.
B. Motor vehicle accident: This also represents an acute stressor because it is a specific event with a defined beginning and end.
C. Living in poverty: This is an example of chronic stress as it involves ongoing, persistent stress over an extended period of time, affecting multiple aspects of life.
D. Loss of a loved one: While this is a significant stressor, it is often acute because it refers to a specific event. Chronic stress involves continuous or repeated stress over time.

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Which of the following is essential when restraints are applied to a client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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