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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Related Questions
Correct Answer is B
Explanation
A. Change in marital status: This is a psychological and social stressor rather than a physiological one.
B. Burn injury: A burn injury is a physiological stressor because it directly affects the body's physical systems and functions, causing a stress response.
C. Academic pressure: This represents a psychological and emotional stressor, impacting mental health and well-being, rather than physical systems.
D. Financial difficulties: Financial difficulties are psychological and social stressors, affecting emotional and mental health rather than physiological processes.
Correct Answer is C
Explanation
A. The goal of hospice care is to prolong life: Hospice care focuses on providing comfort and improving quality of life rather than prolonging life. It is aimed at managing symptoms and supporting patients and families when a cure is no longer possible.
B. Hospice care is limited to clients who are in a health care facility: Hospice care can be provided in various settings, including the patient's home, nursing homes, or hospice facilities. It is not limited to health care facilities.
C. Hospice care is restricted to clients who are terminally ill: Hospice care is specifically designed for individuals who are terminally ill, typically with a prognosis of 6 months or less to live if the disease runs its usual course. This ensures the care is appropriate and focused on end-of-life comfort.
D. Hospice care cannot be discontinued once it is initiated: Hospice care can be discontinued if the patient's condition improves or if they decide to pursue curative treatment. It is not a permanent commitment.
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