A nursing student is in her senior year of nursing school. She is caring for three patients for a busy surgical unit. One of the patients is confused and has been restrained to prevent him from injuring himself
Which of the following is a priority as she plans her care for the shift? A. Calling the physician for an order for a chemical restraint
B. Requesting restraint alternatives from the physician for her patient who is restrained
C. Removing the restraints on the patient at least every 2 hours
D. Checking on the restrained patient last because he cannot get out of bed
C
Assess proper placement of restraint, skin integrity, pulses, temperature, color, and sensation of the restrained body part. Remove restraints at least every 2 hours or more frequently as determined by agency policy. If patient is violent or noncompliant, remove one restraint at a time and/or have other staff present while removing restraints.
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A teenage boy who was the victim of a near drowning has been admitted to the emergency department. The patient was submerged for several minutes and remains unconscious
What pathophysiological process has occurred as a result of the submersion? A) Atrophy of brain cells B) Cellular lysis C) Hypoxia to the brain D) Necrosis to the brain
A kindergarten teacher refers a student to the school nurse because he appears unable to engage in play with the other children and insists on playing alone with a particular toy. He also shows delayed language development
What disorder might the nurse suspect? 1. Conduct disorder 2. Autism spectrum disorder (ASD) 3. Posttraumatic stress disorder (PTSD) 4. Attention-deficit/hyperactivity disorder (ADHD)
A patient has just been diagnosed with type 2 diabetes. The health care provider has prescribed an oral antidiabetic agent that will inhibit the production of glucose by the liver and thereby aid in the control of blood glucose
What type of oral antidiabetic agent has been prescribed for this patient? A) Sulfonylurea B) Biguanide C) Thiazolidinedione D) Alpha glucosidase inhibitor
While conducting a physical assessment the nurse detects atrophic changes on a patient's lower extremities. What physical findings did the nurse assess in this patient?
Select all that apply. 1. thick toenails 2. skin ulcerations 3. dilated leg veins 4. skin discolorations 5. absence of hair on the lower legs