Which of the following principles should guide the use of restraints?
A) The most restrictive device is used for as long as necessary.
B) The least restrictive device is used for the least time possible.
C) Restraints are used any time the patient will not cooperate.
D) Restraints are used as a means of behavior management.
B
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A 78-year-old client with moderate dementia has been transferred to a long-term care facility. The client has a feeding tube. During the admission process, his wife expresses an interest in restoring natural feeding methods for her husband
What information can be provided regarding her inquiry? A) In the client with dementia, the restoration of natural feeding is highly unlikely. B) One of the chief determining factors of the success of this transition will rest with his functional eating abilities. C) The dietitian will need to make the final determination if this is a viable plan. D) This option may be risky, as it requires the feeding tube to be removed prior to the initiation of the natural feeding.
The nurse planning care of a client with multiple myeloma includes the intervention of
a. administering frequent mouth care. b. encouraging ingestion of dairy products. c. forcing fluids. d. maintaining reverse isolation.
The physician asks the nurse if the client with schizophrenia is experiencing any negative symptoms. The nurse says that the client frequently:
A) has visual hallucinations of seeing polar bears in the room. B) is still delusional and believes she is Marilyn Monroe. C) answers questions in one- and two-word phrases with little expression. D) dresses in brightly colored, mismatched outfits.
A nurse is ordered to observe a female client suspected to have meningitis for positive Brudzinski's sign. Which of the following would the nurse document as a positive Brudzinski's sign?
A) Evidence of pain when the client lies on the back and brings one leg up so that the hip and knee are flexed at 90 degrees. B) Evidence of pain when the client lies on the side and brings one leg up so that the hip and knee are flexed at 90 degrees C) Evidence of pain or resistance when the client lies on the back and brings her head forward toward the chest D) Evidence of pain or resistance when the client lies on the side and brings her head forward toward the chest