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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Provide written educational material for the client: While important, this action is not the first step as it assumes the client is ready to receive and understand the information.
B. Ask the client to demonstrate checking their blood sugar: This is a practical step but should come after assessing the client’s readiness to learn and understanding their current knowledge.
C. Identify short-term goals for the client: Goal-setting is crucial but should follow an assessment of the client's readiness to learn to ensure that goals are realistic and tailored to their current level of understanding.
D. Determine the client's readiness to learn: This is the first step in the teaching process as it helps tailor the teaching plan to the client's current state of mind, comprehension level, and willingness to engage with the educational material.
Correct Answer is A
Explanation
A. Compassion fatigue: Correct. Compassion fatigue is characterized by emotional exhaustion and a reduced ability to empathize due to prolonged exposure to others' suffering, which fits the nurse’s experience of feeling overwhelmed and difficulty feeling sympathy.
B. Adventitious stress: Incorrect. Adventitious stress refers to stress caused by external, unexpected events such as natural disasters or accidents, not by ongoing exposure to clients' suffering.
C. Prolonged grief disorder: Incorrect. Prolonged grief disorder involves intense and persistent grief following a loss, not the emotional exhaustion or empathy issues described by the nurse.
D. Post-traumatic stress disorder (PTSD): Incorrect. PTSD is characterized by severe anxiety, flashbacks, and intrusive thoughts related to trauma, not primarily by empathy fatigue or feeling overwhelmed by others' suffering.
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