When preparing to apply a restraint to a child, what would be most important for the nurse to do?
A) Expect to keep the restraint on for at least 8 hours.
B) Explain that safety, not punishment, is the reason for the restraint.
C) Plan to use a square knot to secure the restraint to the side rails.
D) Use a limb restraint rather than a jacket restraint for most issues.
Ans: B
Before applying a restraint, the nurse needs to explain the reason for the restraint to the child, emphasizing that the restraint is for safety, not to punish the child. The least restrictive type of restraint should be used, and it should be applied for the shortest time necessary. A clove-hitch knot is used to secure the restraint with ties to the bed or crib frame, not the side rails.
You might also like to view...
The nurse instructs an older adult who has developed shingles regarding risk for future occurrences of the disease. Which of the following should then nurse include in this discussion?
A) "Chronic diarrhea and thrush are symptoms that can develop years after herpes zoster has invaded the body.". B) "Herpes zoster is a sexually transmitted disease.". C) "You should receive the vaccination to prevent future occurrences.". D) "Your family is now at risk for developing shingles.".
A nurse is evaluating a patient admitted to the emergency department with an evolving STEMI for possible administration of thrombolytic therapy. Which information, identified during history taking, would contraindicate this type of therapy?
a. The patient just completed her last men-strual cycle. b. The patient states that the chest pain started 1 hour ago. c. The patient has a history of a small cere-bral aneurysm. d. The patient has hypertension that is well controlled by diuretic therapy.
The nurse is identifying nursing diagnoses for a patient with gestational hypertension. Which diagnosis would be the most appropriate for this patient?
A) Risk for injury related to fetal distress B) Imbalanced nutrition related to decreased sodium levels C) Ineffective tissue perfusion related to poor heart contraction D) Ineffective tissue perfusion related to vasoconstriction of blood vessels
The drug of choice in treating a recent arteriole occlusion is
A. heparin B. Coumadin C. streptokinase D. vitmain K