Author Question: A nurse walks into a room and finds a patient to be severely confused. The nurse examines and ... (Read 34 times)

bobbysung · **on:** Jul 22, 2018

A nurse walks into a room and finds a patient to be severely confused. The nurse examines and observes the patient closely and thinks about other situations with severely confused patients be-fore making a nursing diagnosis.

Which skill is the nurse using? a. Clinical inferences
b. Reflective journaling
c. Accountability
d. Intuition

Question 2

Which of these statements regarding the use of physical restraints is TRUE?

a. The need for a health care provider's order varies from state to state.
b. Physical restraints are applied when chemical restraints are ineffective.
c. The nurse's responsibility in meeting the client's basic needs increases.
d. Restraints must be reevaluated during every shift for need and correct placement.

sultansheikh · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

A
Part of diagnostic reasoning is clinical inference, the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis. Reflective writing requires you to record your clinical experiences in your own words in a personal journal. Intuition is an inner sensing or gut feeling about something. Accountability refers to being answerable for one's actions.

Answer to Question 2

C
The nurse's responsibility in meeting the client's basic needs increases as the client is restrained and unable to meet their own needs. Restraints must be released once every 2 hours, the nurse must assess the color, temperature, sensation motion, and capillary refill in the area distal to the restraint and perform range-of-motion exercises. The client should also be toileted at this time minimally and have fluids in reach at all times unless contraindicated. The call light must also be in reach at all times so the client may call for assistance as needed.