When caring for a client requiring the use of arm restraints to prevent the client from self-harm, the nurse would perform which of the following implementations?
1. Assess the need for restraints every 24 hours.
2. Remove the restraints for five minutes every four hours.
3. Perform ROM on the restrained limbs once a shift.
4. Offer food, fluid, and toileting every two hours.
4
Rationale 1: If the client is not NPO, basic care is offered every two hours. The need for restraints, ROM to the restrained limb, and removal of one restraint at a time are assessed or performed every two hours.
You might also like to view...
An older male adult is taking aripiprazole (Abilify) for agitation. Which patient assess-ment is the nurse's priority to prevent catastrophic effects of the medication?
a. Oral and facial dyskinesia b. Mask facies, shuffling gait c. Muscle spasms of the face d. Repetitive aimless walking
During a sleep study test, the patient states, "I never dreams anymore." The health care provider tells the patient that everyone dreams, but most people forget about them upon awakening
The health care provider tells the patient that the best way to remember dreams is to do which of the following? a. Eat spicy food before going to sleep. b. Avoid caffeine in the afternoon. c. Consciously think about the dreams upon awakening. d. Become more creative.
The parents of a 2-year-old child tell the nurse they are concerned because the toddler has started to use "baby talk" since the arrival of their new baby. What should the nurse recommend?
a. Ignore the baby talk. b. Tell the toddler frequently, "You are a big kid now." c. Explain to the toddler that baby talk is for babies. d. Encourage the toddler to practice more advanced patterns of speech.
A wound created for therapy is:
a. An open wound b. A clean wound c. A closed wound d. An intentional wound