Question 1

The nurse is preparing to ambulate the client in the hall.Which action by the nurse is a strategy to reduce the client's risk of falls?

Accepted Answer

Encouraging the client to wear nonskid footwear is a strategy to reduce the risk of falls by providing better traction and stability.

Question 2

The nurse completes yearly training regarding the use of restraints.Which situation would the nurse categorize as a restraint?

Accepted Answer

The use of all four side rails on the bed, especially after administering preoperative sedation, is considered a restraint because it restricts the patient's freedom to move and can prevent them from voluntarily getting out of bed, thus requiring intervention for release.

Question 3

The nurse is instructing the unlicensed assistive personnel (UAP)on fall prevention for the clients.Which statement made by the UAP warrants further instruction?

Accepted Answer

The statement "I don't have to worry about the clients who are bedridden, as they are moved by the staff" warrants further instruction because even bedridden clients are at risk of falls or injuries if they attempt to move or get out of bed without assistance. It's important for all staff to be vigilant about fall prevention for all clients, regardless of their mobility status.

Question 4

Prior to or immediately after applying restraints,the nurse must document the use of restraints in the medical record.Which item is not required in the documentation for this client?

Accepted Answer

The health care provider's order for use of restraints is required before applying restraints, but it is not part of the immediate documentation by the nurse. The nurse documents the need, type, and reason for restraint, and that the need was communicated to the client or support people.

Question 5

The nurse is caring for a young pediatric client who is focused on pulling out the IV line in the right arm.Which type of restraint is the most appropriate for this client?

Accepted Answer

The answer of The nurse is caring for a young...

Question 6

The nurse is providing care to a client requiring restraints.How often does the nurse assess the client and document the assessment?

Accepted Answer

The nurse must assess the client and document the assessment once every 1-2 hours when restraints are used to ensure the client's safety and well-being, and to comply with guidelines for the ethical and safe use of restraints.

Question 7

The nurse is providing care to a client who is diagnosed with paranoid schizophrenia.The client is threatening the staff and believes the staff is trying to harm him.When the nurse enters the client's room,the client is agitated,and attempts to slap the nurse.The nurse gets assistance from other staff members and restrains the client.Which nursing action is the priority at this time?

Accepted Answer

The priority nursing action at this time is to notify the health care provider of the need to see the client within the hour. This allows the provider to assess the client's condition and determine the appropriate course of action. Requesting a psychiatric referral is important, but it may not be an immediate priority in this situation. Padding the side rails is a safety measure, but it does not address the client's immediate needs. Obtaining consent for use of restraints is important, but it may not be possible or feasible in an emergency situation where the client is threatening harm.

Question 8

Which is required by the nurse prior to putting the bed or chair exit safety-monitoring device in place?

Accepted Answer

Testing the alarm is necessary to ensure it functions properly before use.

Question 9

The nurse is caring for a client who consistently pulls at the IV and urinary catheter.Restraints are applied that prevent the client from being able to grasp the tubing.Which term will the nurse use when documenting the restraints used for this client?

Accepted Answer

Mitt restraints are specifically designed to prevent clients from being able to grasp or pull at IVs, catheters, or other medical equipment while allowing for some movement and freedom for the client's hands. Jacket restraints typically surround the torso and limit upper body movement, waist restraints limit mobility around the waist, and limb restraints limit mobility of a specific limb. None of these options would be as appropriate for preventing the client from grabbing at tubing.

Question 10

Which action performed by the nurse will not reduce the risk of client falls?

Accepted Answer

Placing overbed and bedside tables out of the way does not directly reduce the risk of falls. It may help prevent tripping hazards, but it does not address any of the other factors that contribute to falls, such as mobility, medication effects, and environmental hazards.

Question 11

The nurse is providing care to a client who has an order for a jacket restraint.Which action by the nurse is appropriate when applying this restraint to the client?

Accepted Answer

Using a half-bow knot to secure the tie around the movable part of the bed frame is appropriate because it ensures the restraint can be quickly released in case of an emergency, while also allowing for adjustments to the bed position without compromising the effectiveness of the restraint.

Question 12

The nurse administers an antianxiety (anxiolytic)medication to a client diagnosed with dementia who has been harming himself.When documenting the use of this medication as a restraint,which term is the most appropriate for the nurse to use?

Accepted Answer

The term "chemical restraint" is used when any medication is given to a client to control their behavior or restrict their movement, in order to maintain safety. In this scenario, the antianxiety medication is given to prevent the client from harming himself, and thus qualifies as a chemical restraint. The other options, physical restraint, medication restraint, and psychological restraint, are not commonly used or recognized terms in healthcare.

Question 13

The unlicensed assistive personnel (UAP)informs the nurse that the client has pulled the IV catheter out again and is not oriented to time or place.Which task could the nurse safely delegate to the UAP at this time?

Accepted Answer

The nurse can delegate the task of getting mitt restraints from the supply room and meeting the nurse in the client's room to the UAP. However, it is not within the UAP's scope of practice to apply restraints or make decisions regarding their use. The nurse must obtain an order from the health care provider before applying any form of restraint.

Question 14

When putting a client in restraints,the nurse will need to assess the client per policy.Which items will the nurse include when assessing this client?

Accepted Answer

The nurse should assess the client's range of motion, vital signs, circulation, and hydration to ensure the client's safety and well-being while in restraints. Tying the restraint in a knot is not appropriate as it can hinder quick release in an emergency.

Question 15

The nurse is caring for a client who has seizure precautions.Which actions by the nurse are appropriate for these precautions?

Accepted Answer

A. Padding the bed around the head, foot, and side rails can help prevent injury to the client during a seizure.

B. Placing functional oral suction equipment in the room is important in case the client experiences any respiratory distress during or after a seizure.

D. Keeping pillows handy to protect the client's head can provide additional cushioning and prevent head injury during a seizure.

C. Placing extremity restraints in the room for use if the client has a seizure is not appropriate. Restraints are not recommended for seizure precautions as they can increase the risk of injury and limit the client's ability to move during a seizure.

E. Taping a bite block to the wall to protect the client from biting his or her tongue is also not appropriate. Bite blocks can cause injury to the teeth and mouth and are not recommended for seizure precautions.

Question 16

The nurse is working in a long-term care facility on a locked Alzheimer unit.Which client assigned to the nurse might require restraints?

Accepted Answer

Restraints may be considered for a client who poses a risk of self-harm, such as the client with numerous self-imposed scratches, to prevent further injury.

Question 17

The nurse is providing an explanation to the client who has a bed alarm.Which statement made by the client indicates an appropriate understanding of the use of a bed alarm?

Accepted Answer

Option A is incorrect as the bed alarm is meant to sound when the client gets out of bed, so they should not be able to remove it. Option B is incorrect as sounding an electric shock would be a form of punishment, which is not the purpose of a bed alarm. Option D is incorrect as the alarm can be secured to different parts of the bed, not necessarily the inner thigh. Option C is the correct answer as it accurately describes the purpose of the bed alarm.

Question 18

The nurse is delegating supportive care to the unlicensed assistive personnel (UAP)for several clients on a medical-surgical unit.Which statement made by the UAP warrants the need for more information?

Accepted Answer

The UAP's statement about untying a restraint requires more information because untying a restraint without proper training and patient assessment could be dangerous and potentially harmful to the patient. The nurse should ensure that the UAP has been properly trained on when and how to remove restraints and under what circumstances it is necessary to contact the nurse for assistance.

Question 19

Which items are appropriate for the nurse to include when assessing a client for falls?

Accepted Answer

Reviewing for a history of falls before admission, assessing the overall physical condition, assessing medication lists, and assessing mental status are all appropriate items to include when assessing a client for falls. Talking with family about concerns can also be helpful, but it is not always possible or necessary.

Quiz 12: Fall Prevention and Restraints