Answer to Question 1
B
Restraints are utilized only when alternatives have been exhausted, the patient continues a behavior that can be harmful to himself or others, and the restraint is clinically justified. In this circumstance, continuing to remove a needed nasogastric tube would meet these criteria. Refusing to call for help, although unsafe, is not a reason for restraint. Getting confused at night regarding the time or not sleeping and bothering the staff to ask for items is not a reason for restraint.
Answer to Question 2
C
All makeup, including nail polish, should be removed to expose normal skin and nail colour to determine the client's level of oxygenation and circulation during and after surgery.
Jewellery and other valuables should be given to family members or secured for safekeeping. A wedding band can be taped in place unless the client might experience swelling of the hand or fingers. For safety, metal items, such as in pierced areas, should be removed.
The client should be NPO (nothing by mouth) before surgery to prevent vomiting and aspiration with general anaesthesia.
Clients may be allowed to keep personal items such as a hearing aid until they reach the preoper-ative area.
Nurses may collaborate with social workers, physicians, and other members of the health care team to
A hearing-impaired patient using an interpreter.
A therapist assisting an amputee patient to regain mobility and strength after amputation.
Algorithm for assessing a patient at risk for self-directed violence.
Koplik spots in the mouth of a patient with measles.