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

A.

Use a square knot.

B.

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

C.

Secure the restraint to the side rail.

D.

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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Related Questions

Correct Answer is D

Explanation

A. Episodic acute stress: This term is not commonly used in clinical practice and does not accurately describe the condition associated with recurring flashbacks of a past traumatic event.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder and is not related to the psychological symptoms described, such as flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after a traumatic event and involves symptoms like flashbacks, but since the traumatic event occurred a year ago, it is more consistent with PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by persistent symptoms such as flashbacks, intrusive memories, and severe anxiety that occur long after the traumatic event, fitting the client's reported symptoms.

Correct Answer is B

Explanation

A. The goal of palliative care is to prolong the life of a client: The primary goal of palliative care is to improve the quality of life by managing symptoms and providing comfort, rather than focusing solely on prolonging life.
B. Palliative care is not restricted to clients who are terminally ill: Palliative care can be provided to clients at any stage of a serious illness, regardless of whether they are terminally ill. It focuses on relief from symptoms and improving quality of life.
C. Palliative care should be avoided for a client who is receiving a cure: Palliative care can be provided alongside curative treatment to manage symptoms and improve quality of life throughout the treatment process.
D. Palliative care is limited to clients who are in a healthcare facility: Palliative care can be provided in various settings, including home care, outpatient clinics, and healthcare facilities.

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