A patient has been placed in four-point leather restraints following a violent episode. The nurse establishing the care plan must ensure that the restraints are removed
a. after a minimum of 12 hours of seclusion.
b. every 2 hours, one restraint at a time, for 10 minutes.
c. to allow the patient to eat, drink, or use the bathroom.
d. after the patient is sedated with antipsychotropic medication.
B
Restraints must be removed at intervals specified by agency protocol (in no case less often than 2 hours) to inspect for injuries, check circulation, and provide limb range of motion. The other options do not follow regulatory policies.
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The physician has ordered a Tensilon test to rule out myasthenia gravis. The nurse knows that which of the following medications would be used to counteract the side effects of the Tensilon?
A) Baclofen (Lioresal) B) Atropine (AtroPen) C) Epinephrine (Adrenalin) D) Narcan (Naloxone)
When assessing the client with multiple café au lait macules (CALMs), the nurse should also be alert for:
A) neurofibromas. B) patches of unpigmented skin. C) alopecia. D) psoriasis.
The oncology nurse is preparing a teaching plan for a patient with Binet Stage B chronic lymphocytic leukemia (CLL). Which patient statement indicates that the patient understands her current stage?
A) "I have two areas of lymph node involvement, and my red cell and platelet counts are good." B) "I have three areas of lymph node involvement, and my red cell and platelet counts are good." C) "I have three areas of lymph node involvement, and my red cell and platelet counts are low." D) "I have two areas of lymph node involvement, and my red cell and platelet counts are low."
Which ethical principle reflects respect for all persons and their self-determination?
a. Autonomy c. Justice b. Beneficence d. Veracity