The nurse is caring for a hospitalized patient. Which behavior alerts the nurse to consider the need for a restraint?
a. The patient refuses to call for help to go to the bathroom.
b. The patient continues to remove the nasogastric tube.
c. The patient gets confused regarding the time at night.
d. The patient does not sleep and continues to ask for items.
ANS: B
Patients who are confused, disoriented, and wander or repeatedly fall or try to remove medical devices (e.g., oxygen equipment, IV lines, or dressings) often require the temporary use of restraints to keep them safe. Restraints can be used to prevent interruption of therapy such as traction, IV infusions, NG tube feeding, or Foley catheterization. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.
You might also like to view...
Prior to discharge from the birth hospital, the new mother asks the nurse about the use of a mobile over the crib. The nurse would explain to the mother that the mobile should be placed about 10 inches above the level of the baby
The nurse would explain that this placement: 1. Is based on the fact that newborns can focus at a distance of 8 to 12 inches. 2. Will prevent the infant from being injured by the mobile. 3. Is most convenient for the parents. 4. Is for decoration only. The newborn does not have vision sufficient to see the mobile.
While working with a client who is living with progressively worsening Parkinson disease and consequent self-care deficits, Nurse P is conscious of integrating principles of holistic gerontological nursing care
Place the following steps in the application of these principles in the correct logical and chronological order. Use all the options. A) Implement specific nursing care plan actions B) Perform an assessment of the client C) Identify the presence of needs related to health challenges D) Evaluate how well identified health needs are being met E) Explore reasons underlying the client's health needs
Barbiturates are nonspecific CNS stimulants designed to redirect impulse transmission in the cortex of the brain to decrease seizures
Indicate whether the statement is true or false.
A nurse manager has an adequate understanding of their nursing role when making which of the following statements?
a. "A manager selects or assumes a role.". b. "I have the same function as a floor nurse.". c. "I have the same authority as the director of the hospital.". d. "I was appointed to my role.".