The nurse is ordered to apply restraints to a toddler who keeps pulling at the tubes in his arm. Which of the following criteria must occur to ensure proper use of these restraints? Select all answers that apply
A) The nurse must check the restraints every 15 minutes while they are in place.
B) Secure the restraints with ties to the side rails, not the bed or crib frame.
C) Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement.
D) Use a clove-hitch type of knot to secure the restraints with ties.
E) Remove the restraint every 2 hours to allow for range of motion and repositioning.
F) Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.
D, E, F
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The data element obtained during nursing assessment that supports the presence of a fugue state is
that the client states he a. cannot recall why he is living in his present location. b. feels as if he is living in a fuzzy dream state. c. feels very anxious about his problems. d. feels that different parts of him are at war.
A patient will be starting therapy with a corticosteroid
The nurse reviews the patient's orders and notes that an interaction may occur if the corticosteroid is taken with which of these drug classes? a. Nonsteroidal anti-inflammatory drugs b. Antibiotics c. Opioid analgesics d. Antidepressants
Your examination of an infant reveals a positive Allis sign. To confirm this finding, you would perform (or elicit) a:
a. startle reflex. b. Barlow-Ortolani maneuver. c. Trendelenburg test. d. tibial torsion test.
Sideroblastic anemia can occasionally result from an autosomal recessive transmission inherited from which relative?
a. Mother b. Father c. Grandfather d. Grandmother