Soft restraints have been placed on a violent teenage girl. The ...

[piesebel]

Soft restraints have been placed on a violent teenage girl. The nursing staff will follow protocol by: (Select all that apply.)
 
  1. Checking to make sure two fingers can be placed between the restraints and the arm.
   2. Releasing the teen from the restraints because they are illegal.
   3. Provide one-on-one staff observations for the girl.
   4. Place the teen in a prone position to provide safety for the staff.
   5. Should not be placed in soft restraints as this is a violation of the Nursing Standards Act.

Question 2

The nurse counsels the parents of a 1-year-old girl on methods to avoid the occurrence of a urinary tract infection, which includes avoiding: (Select all that apply.)
 
  a. Wearing tight underwear or diapers
  b. Drinking carbonated beverages
  c. Cleaning the perineum from back to front
  d. Using talcum powder on the perineal area
  e. Infestation of pinworms

[yasmin]

Answer to Question 1

1, 3
Feedback
1. The two fingers demonstrates that the restrains are snug, but not too tight, causing circulation issues.
2. The restrains are legal because the patient is violent and can cause harm to her or others at this time.
3. One-to-one observation is needed for a safety watch while wearing the restraints.
4. The patient should be placed in a supine position so that the airway is not compromised.
5. This is not a violation if the proper safety measures are observed.

Answer to Question 2

A, C, D, E
Tight underwear, cleaning from back to front, talcum powder, and pinworms all can cause a urinary tract infection.