Which of the following statements accurately describes a letter represented in the R-E-S-T-R-A-I-N-T acronym (Dibartolo, 1998)?
A) Respond to the past history of the patient (including past falls) to determine the need for restraints.
B) Alert the physician and the patient's family if restraints are ordered by the nursing team.
C) Individualize the use of restraints and choose the most restrictive device to provide the best protection for the patient.
D) Time-limit the use of restraints; restraints should be used no longer than 24 hours on nonpsychiatric patients.
D
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When meeting with a client for the first time, the psychiatric–mental health nurse applying psychobiological principles is most likely to make which of the following statements?
1. "Your abnormal behavior is directly related to living in an unsupportive environment." 2. "You have a brain lesion and can expect to be hospitalized many times over the course of your life." 3. "We are thoroughly assessing your symptoms because an accurate diagnosis is the basis of your treatment." 4. "It is fairly certain that your children will feel stigmatized by their peers."
The nurse is conducting a clinic visit with a mother and an adolescent client. Both the mother and the adolescent report that the adolescent does not go to sleep until late at night and then wakes up late in the morning
The mother states, "I don't know what to do." Which response by the nurse is the most appropriate? A) Inform her that adolescents experience changes in the body's internal clock associated with puberty. B) Recommend a polysomnography (PSG). C) Tell her to avoid giving her son any herbal preparations such as melatonin. D) Inform them that the son's sleep habits, such as bringing electronic devices to bed, have no effect on his sleep pattern.
A nurse is preparing to draw blood from a client. Where should the tourniquet be applied?
a. 2 inches above the venipuncture site b. 3 to 4 inches above the venipuncture site c. 5 inches above the venipuncture site d. 6 to 7 inches above the venipuncture site
A surgical patient is receiving succinylcholine (Anectine) with an inhalation anesthetic. The patient is intubated, has an indwelling urinary catheter, and has ongoing monitoring of vital signs
Which symptom during the perioperative period is cause for concern? a. Elevated temperature b. Increased urine output c. Muscle paralysis d. No response to painful stimuli