Review Practice Exercise 3

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Practice Exercise 3

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Total Questions : 5

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Question 1:

Joint Commission guidelines regarding the use of restraints recommend which of the following?

A. Vest restraints be used because they are the least restrictive type B. Restraints should be used for 48 hours in nonpsychiatric patients C. Restraints should be applied to prevent wandering behavior D. Alternative measures must be attempted first

Answer and Explanation

Choice A:

Vest restraints be used because they are the least restrictive type: Vest restraints are not considered the least restrictive; in fact, they pose a high risk of injury or death from strangulation.

Choice B:

Restraints should be used for 48 hours in nonpsychiatric patients: The Joint Commission requires that restraint orders for nonpsychiatric patients be renewed every 24 hours (or less), and the patient must be continually reassessed. A fixed “48 hours” policy violates these safety guidelines.

Choice C:

Restraints should be applied to prevent wandering behavior: Restraints are not indicated for preventing wandering, especially in patients with dementia. Wandering should be managed through safe environmental modifications, supervision, and redirection rather than physical restriction.

Choice D:

Alternative measures must be attempted first: TJC standards require that restraints be a last resort after less restrictive alternatives (such as sitter observation, environmental adjustments, or de-escalation) have been tried and documented. Rationale for incorrect answers:

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Question 2:

An older resident who is disoriented likes to wander the halls of his long-term care facility. Which of the following would be most appropriate for the nurse to use as an alternative to restraints?

A. Sitting him in a geriatric chair near the nurses’ station B. Using the sheets to secure him snugly in his bed C. Keeping the bed in the high position D. Identifying his door with his picture and a balloon

Answer and Explanation

Choice A:

Sitting him in a geriatric chair near the nurses’ station: Can be restrictive if used to immobilize him; it doesn’t promote orientation and may increase agitation over time.

Choice B:

Using the sheets to secure him snugly in his bed: Unsafe and constitutes an improper restraint - risk of injury, suffocation; inappropriate.

Choice C:

Keeping the bed in the high position: Dangerous- increases fall risk if he tries to climb out and can lead to serious injury; not an accepted safety practice.

Choice D:

Identifying his door with his picture and a balloon: Visual cues (photo, personalized decorations) help orient confused residents and reduce unsupported exits/wandering by making their room recognizable. Rationale for incorrect answers:

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Question 3:

Nursing education efforts that focus on prevention of firearm injuries are important for which of the following reasons?

A. The elderly population is particularly at risk for firearm injuries. B. Most homicide victims, 10 to 24 years of age, are killed with a gun. C. The National Safety Council recommends a gun in every household to protect its members. D. They have contributed to a decrease in injuries and deaths from guns.

Answer and Explanation

Choice A:

The elderly population is particularly at risk for firearm injuries: Older adults are at elevated risk of firearm suicide in some countries, but they are not the primary group for firearm homicide risk.

Choice B:

Most homicide victims, 10 to 24 years of age, are killed with a gun: Firearms account for a large proportion of homicides among adolescents and young adults. That pattern makes firearm-safety education (safe storage, reducing youth access) especially important to lower youth mortality.Rationale for incorrect answers:

Choice C:

The National Safety Council recommends a gun in every household to protect its members: Safety organizations emphasize risk reduction (safe storage, education), not recommending firearms as a universal household safety measure.

Choice D:

They have contributed to a decrease in injuries and deaths from guns: Education helps, but alone it has not reliably driven population-level decreases in firearm deaths; multifaceted strategies (policy, safe storage laws, access reduction, and community programs) are typically needed.

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Question 4:

The nurse, at change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the nurse is appropriate? Select all that apply

A. Document the behavior(s) that require continued use of the restraints. B. Ensure that the restraints are tied to the side rails. C. Provide range-of-motion exercises when the restraints are removed. D. Orient the client. E. Assess the tightness of the restraints.

Answer and Explanation

Choice A:

Document the behavior(s) that require continued use of the restraints: You must document the specific behaviors that justify restraint use (e.g., pulled IV, attempts to get OOB), the alternatives tried, the type/time of restraint, and ongoing reassessments.

Choice B:

Ensure that the restraints are tied to the side rails: Restraints must be secured to the bed frame (a immovable part) or use quick-release ties per policy - not to side rails, because side rails move and can cause entrapment or increased fall risk if the rail is raised/lowered.

Choice C:

Provide range-of-motion exercises when the restraints are removed: Periodic release of restraints (per policy, often at least every 2 hours) with ROM, repositioning, skin checks, toileting and nourishment prevents complications (contractures, skin breakdown, circulatory problems).

Choice D:

Orient the client: Reorientation, explanation of why restraints are used, and reassurance are nonpharmacologic, least-restrictive interventions that should be used continuously to reduce agitation and possibly shorten restraint duration.

Choice E:

Assess the tightness of the restraints: Regular neurovascular checks (capillary refill, pulses, sensation, color, temperature) and ensuring you can fit about two fingers between the restraint and skin are essential to prevent ischemia and nerve injury.Rationale for incorrect answers:

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Question 5:

A client is being admitted to the hospital because of a seizure that occurred at his home. The client has no previous history of seizures. In planning the client’s nursing care, which of the following measures is most essential at this time of admission? Select all that apply

A. Place a padded tongue depressor at the head of the bed. B. Pad the bed with blankets. C. Inform the client about the importance of wearing a medical identification tag. D. Teach the client about epilepsy. E. Test oral suction equipment.

Answer and Explanation

Choice A:

Place a padded tongue depressor at the head of the bed: Tongue depressors (padded or not) should never be placed in the mouth of a seizing client, as this can cause choking, dental injury, or airway obstruction.

Choice B:

Pad the bed with blankets: Padding protects the client from injury during involuntary movements of a seizure, especially if the seizure occurs while in bed.

Choice C:

Inform the client about the importance of wearing a medical identification tag: While important for long-term management, this is not essential during the admission phase, especially when the diagnosis is still being investigated.

Choice D:

Teach the client about epilepsy: The client has had a single seizure and does not yet have a diagnosis of epilepsy. Education should be based on confirmed conditions.

Choice E:

Test oral suction equipment: Ensuring suction is functional prepares the nurse to clear secretions and maintain a patent airway if the client has another seizure, especially if vomiting or excessive saliva occurs.Rationale for incorrect answers:

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Practice Exercise 3

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