The nurse is preparing to write her nursing progress notes for a ...

[melly21297]

The nurse is preparing to write her nursing progress notes for a patient who has wrist restraints. Which of the following will the nurse include in her progress notes? Select all that apply.
 
  a. Family teaching initiated regarding the need for patient restraint
  b. Restraint removed once per shift to assess skin color, sensation, and movement of extremity
  c. A prescription for wrist restraint received from the primary care provider
  d. Wrist restraints applied because of the patient's increasing confusion

Question 2

A patient's jugular venous pressure measures 5 cm. This finding indicates:
 
  a. A normal finding
  b. Hypovolemia
  c. Heart failure
  d. Dehydration

[covalentbond]

Answer to Question 1

A, C
There are times when restraints are used, although research indicates that less restraint use saves time and money, and reduces patient injuries. A restrained person has a natural tendency to struggle and try to remove the restraint; as a result, the person can become entangled and suffer nerve damage, circulatory impairment, and even suffocation. There are laws and guidelines for the use of restraints and nurses need not only to follow all guidelines, but also to provide appropriate and accurate documentation. Included in nursing documentation are the following: An order or prescription for restraints, notation for removal of a restraint every 2 hours to assess skin and circulation, provision for feeding and toileting, and, when applicable, an explanation of the need for restraints the to a patient's family/significant other. The reason for restraint should be documented; however, in this item, confusion alone is not enough information to warrant the need for the restraint.

Answer to Question 2

C
Normal jugular venous pressure is less than 3 cm. A jugular venous pressure of 5 cm is elevated and suggests heart failure.