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 C
Explanation
A. Bronchial airway constriction: In the fight-or-flight response, bronchial airways actually dilate to increase airflow to the lungs, rather than constricting.
B. Hypoglycemia: The fight-or-flight response typically leads to increased blood glucose levels (hyperglycemia) to provide quick energy, not decreased levels.
C. Dilated pupils: During the fight-or-flight response, pupils dilate to improve vision and help the individual better detect threats. This is a classic manifestation of this stress response.
D. Decreased blood pressure: The fight-or-flight response generally increases blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
Correct Answer is D
Explanation
A. Episodic acute stress: This term is not a recognized diagnosis. Acute stress disorder and posttraumatic stress disorder are the established diagnoses related to trauma and stress.
B. Irritable bowel syndrome (IBS): IBS is a gastrointestinal disorder characterized by abdominal pain and altered bowel habits. It is not related to the flashbacks of traumatic events.
C. Acute stress disorder (ASD): ASD occurs within the first month after exposure to a traumatic event and involves symptoms like intrusive memories and flashbacks. However, since the traumatic event occurred a year ago, this disorder is less likely than PTSD.
D. Posttraumatic stress disorder (PTSD): PTSD is characterized by symptoms such as flashbacks, nightmares, and severe anxiety following exposure to a traumatic event. Given the traumatic event happened a year ago, the client’s symptoms are consistent with PTSD.
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