Exam 12: Fall Prevention and Restraints

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?

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?

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?

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?

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?

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

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?

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

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?

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

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?

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?

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

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

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

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?

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

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

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?