Which of the following assessment findings is most critical for a patient who is currently being restrained with mechanical wrist restraints?
a. Angry, loud crying
b. Urinary incontinence
c. Reddened areas on wrists
d. Hands cool to the touch
D
Feedback
A Angry, loud crying is a concern for the patient, but it is not the most critical concern of the patient with mechanical wrist restraints.
B Urinary incontinence is a concern for the patient, but it is not the most critical concern of the patient with mechanical wrist restraints.
C Reddened areas on the wrists are a concern for the patient, but it is not the most critical concern for the patient with wrist restraints.
D While the use of any restraint may be associated with serious complications, including pressure ulcers, constipation, pneumonia, urinary and fecal incontinence, and urinary retention, the most serious concerns are contractures, nerve damage, and circulatory impairment. The coolness of the patient's hands indicates poor circulation and can result in permanent damage.
You might also like to view...
You recently acquired a position as a unit manager. During your time on the unit, you have formed a strong social network among your staff, have promoted the development of relation-ships between your staff and workers in other areas of the
organization, and have formed rela-tionships that generate ideas from patient organizations and the local nursing education program. According to complexity theory, you are engaging which principle? a. Empowerment b. Systematic thinking c. Development of networks d. Bottom-up interactions
A patient is admitted to the critical care unit with an acute head injury after a motor vehicle accident
The patient has a Glasgow Coma Scale score of 6 . The patient is intubated and ventilated, and a ventriculostomy is placed with physician orders to keep the ICP less than 15 mm Hg. The patient's ICP continues to rise despite aggressive intervention. Which of the following is an advantage of a ventriculostomy ICP monitoring system? a. Lower risk of infection b. Ease of insertion c. No penetration of brain d. Access for cerebrospinal fluid drainage and sampling
Which of the special equipment devices is not primarily used to prevent skin breakdown?
a. air-filled mattress c. sheepskin b. egg crate mattress d. hand-wrist splints
When preparing for patient teaching what should the nurse do first?
a. Assess the learner's needs. b. List key points to be presented. c. Collect the teaching materials. d. Think about how the skill can be done at home.