Difficulty: Medium
Average Score: 88%
Simulated
A nurse is planning care for a hospitalized client who is immobile and in a continuous mitten restraint. Which of the following interventions should be included in the client's care plan? (Select all that apply.)
Correct answer
A,B,C,D
Rationale
Correct Answer: A, B, C, D
Rationale:
A: Obtaining provider's prescription renewal every 72 hr ensures ongoing assessment of the necessity for restraints.
B: Documenting restraint checks and client status every 2 hr ensures monitoring for any adverse effects and compliance with regulations.
C: Implementing passive range-of-motion exercises prevents contractures and maintains joint mobility in an immobile client.
D: Educating the client's family about restraint use promotes understanding and compliance, reducing the risk of complications.
Summary of Incorrect Choices:
E: Releasing the restraint and repositioning the client every 4 hr may not be appropriate as it can lead to potential harm or injury if the client is agitated or at risk of falling.
F:
G:
In summary, the correct interventions focus on monitoring, prevention of complications, and education, while the incorrect choices may pose risks to the client's safety.
Rationale:
A: Obtaining provider's prescription renewal every 72 hr ensures ongoing assessment of the necessity for restraints.
B: Documenting restraint checks and client status every 2 hr ensures monitoring for any adverse effects and compliance with regulations.
C: Implementing passive range-of-motion exercises prevents contractures and maintains joint mobility in an immobile client.
D: Educating the client's family about restraint use promotes understanding and compliance, reducing the risk of complications.
Summary of Incorrect Choices:
E: Releasing the restraint and repositioning the client every 4 hr may not be appropriate as it can lead to potential harm or injury if the client is agitated or at risk of falling.
F:
G:
In summary, the correct interventions focus on monitoring, prevention of complications, and education, while the incorrect choices may pose risks to the client's safety.