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The nurse is preparing to restrain a client using soft-limb restraints. When initially restraining the client, it would be a priority for the nurse to
- A. Update the client's family on the use of the restraint.
- B. Obtain the client's pulse and blood pressure.
- C. Offer a snack and fluids.
- D. Inform the client the reason why they are being restrained.
Correct Answer: D
Rationale: Informing the client of the restraint’s reason promotes understanding and compliance, a priority for safety and ethics. Other actions are secondary.
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The nurse is caring for a client who has been physically violent towards staff. The nurse prepares to restrain the client using
- A. soft wrist restraints.
- B. mitten restraints.
- C. elbow restraints.
- D. waist belt restraint.
Correct Answer: A
Rationale: Soft wrist restraints are appropriate for preventing harm in violent clients while allowing some movement. Other options are less suitable.
The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 1 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
Select the three (3) client findings that require immediate follow-up for a 67-year-old female client with progressive multiple sclerosis.
- A. reports of fatigue
- B. heat sensitivity
- C. activity intolerance
- D. medication adherence
- E. ambulation assistance
- F. muscle incoordination
- G. characteristics of pain
Correct Answer: D,E,F
Rationale: Medication adherence (incomplete antibiotic course) risks recurrent cystitis, ambulation assistance (using furniture) indicates fall risk, and muscle incoordination increases injury risk, requiring immediate intervention.
The nurse is caring for a client in bilateral soft wrist restraints. The nurse should assess the client's? Select all that apply.
- A. behavioral status.
- B. skin integrity.
- C. bowel sounds.
- D. neurovascular status.
- E. need for restraint.
Correct Answer: A,B,D,E
Rationale: Behavioral status, skin integrity, neurovascular status, and need for restraint must be assessed to ensure safety and appropriateness of restraints. Bowel sounds are unrelated.
A nurse is caring for a client who has complete immobility and is bedbound. Which of the following complications should the nurse monitor for? Select all that apply.
- A. Peripheral neuropathy
- B. Increased peristalsis leading to diarrhea
- C. Joint contractures
- D. Increased bone density
- E. Peripheral edema
- F. Pneumonia
Correct Answer: C,E,F
Rationale: Immobility causes contractures, edema, and pneumonia due to reduced mobility and lung expansion. Neuropathy and increased peristalsis are unrelated, and bone density decreases.
The nurse is teaching a parenting class on infant car seat safety. Which statements should the nurse include? Select all that apply.
- A. Place the car seat rear-facing in the back seat and at 90 degrees.
- B. The car seat straps should fit snugly over the shoulders.
- C. Infants should ride in a car seat, rear-facing, in the back seat, until six months.
- D. Rolled blankets may be needed between the crotch and legs to prevent slouching.
- E. You may add padding underneath the infant to increase their comfort.
Correct Answer: B,D
Rationale: Snug straps and rolled blankets for positioning are correct. Rear-facing should be until at least 2 years, not 90 degrees, and padding underneath is unsafe.