Question: QUESTION 25 What Circumstances Are Appropriate To Use Restraints? SELECT ALL THAT APPLY. A. To Ensure The Physical Safety Of The Staff B. To Prevent A Fall C. To Prevent The Disruption Of Therapy D. When The Patient Has No Family E. Before Distraction Measures Are Attempted QUESTION 26 The Nurse Has Applied Mitt Restraints To A Child That Was Pulling …

QUESTION 25 What circumstances are appropriate to use restraints? SELECT ALL THAT APPLY. a. To ensure the physical safety of the staff b. To prevent a fall c. To prevent the disruption of therapy d. When the patient has no family e. Before distraction measures are attempted QUESTION 26 The nurse has applied mitt restraints to a child that was pulling at their IV site and tubing. What should the nurse assess related to the use of the restraint? SELECT ALL THAT APPLY. a. Skin condition beneath the restraint device b. Family member’s reaction to the intervention c. IV site, condition and status d. Behavior(s) that justify the application of the restraints e. Pulse and capillary refill time to the restrained limb(s) The nurse is caring for a 40-year old patient who has pulled out their urinary catheter twice, and now has hematuria. The healthcare provider has ordered restraints, what type of restraint should the nurse anticipate? O a. All 4 side rails up O b. Belt restraint O c. Extremity restraint d. Vest restraint QUESTION 21 Identify the conditions that place the patient at risk for aspiration, thus requiring aspiration precautions. SELECT ALL THAT APPLY. a. Sepsis and septic shock b. Hemorrhagic stroke c. Traumatic brain injury d. Lung cancer e. Sedation from medication QUESTION 22 Identify the signs and symptoms of silent aspiration. SELECT ALL THAT APPLY. a. Pocketing food b.Absence of a gag reflex c. Coughing with swallowing d. Sensation of food stuck in throat e. Depressed alertness