211 Exam 3 - topics: cognition, pain, tissue integrity; skills: catheters

guidelines for restraint 1

- Patient has the right to be free from unneeded restraints. (extremity restraints are worse than body) - Patient's family must be involved in the patient's plan of care. - Restraints should be considered only after complete assessment of patient, environment, and situation. - Alternatives to restraints have been tried and contraindications to restraints assessed. - Benefit of restrain use must outweigh the risks.

validation therapy

- Primary goal: to give a sense of identity, dignity, & self-worth - Empathize with feelings and meanings hidden behind their confused speech and behavior developed by researcher Naomi Feil, was originated because of studies that showed lack of efficacy of reality orientation. Feil suggested that some of the features associated with dementia, such as retreating into the past, are active strategies on the part of the affected individual to avoid stress, boredom, and loneliness. Feil believes that people with dementia can retreat into an inner reality based on feelings rather than intellect, because they find the present reality too painful. Validation therapists, therefore, attempt to communicate with individuals with dementia by empathizing with the feelings and meanings hidden behind their confused speech and behavior. The caregiver focuses on what is important to the patient and what time period in life was most influential to the patient and uses these memories to motivate the patient. Validation therapists deal with the patient in the time frame that the patient feels comfortable with. If the patient concentrates on past events in life, this is supported. Caregivers assess the patient's reality and work within the patient's world rather than try to reorient the patient to the present. Some investigators assert that validation therapy promotes contentment, results in less negative affect and behavioral disturbance, produces positive effects, and provides the individual with comfort.

guidelines for restraints 2

- Restraints must be ordered by a physician or licensed practitioner. - Patient must be monitored and reassessed (assess every hour and remove every 2h). - Patient's personal, nutritional, and elimination needs must be met. - Skin integrity must be assessed and range-of-motion exercises performed. - Documentation of why, how, where, and for how long the restraints were placed, and patient monitoring is vital.

delirium

- three categories exist: hyperactive, hypoactive, mixed. - Key features of delirium: acute onset, fluctuating course, inattention, disorganized thought, and altered level of consciousness. - caused by lots of factors, most common reason is polypharm (four drugs in combination), also acute illness, trauma, renal impairment, dehydration, hypoglycemia. Anticholinergics should be reassessed as they can precipitate delirium: atropine, digoxin, diphenhydramine, hydroxyzine, furosemide, prochlorperazine, prednisolone, scopolamine, tricyclic antidepressants

Removal of Foley Catheter

- use clean technique - deflate balloon completely, using gravity to remove it. Empty water from syringe, then reattached syringe and check for water one more time - let pt. know that they might have decreased bladder tone or urethral irritation for a bit, and should drink lots of water - use a waterproof pad between pt's thighs - remove leg strap first, then take tube out - ask pt to take a few deep breaths, then take it out slowly and carefully - doc size, cath, and pt. response to cath. Also document unusual assessment, when pt should urinate, and input/outputs

pain assessment tools

-Wong-Baker FACES - 1-10 scale of unhappy faces -Beyer Oucher pain scale -CRIES pain scale -FLACC scale -COMFORT scale (if a pt is unable to describe their pain)

PAINAD scale

0-10 pain scale for advanced dementia, based on pure observation. assesses 5 common behaviors: breathing, vocalization, facial expression, body language, and consolability. A score of 4 or above indicates a need for pain management.

Which of the following accurately describes a practice guideline that the nurse should follow when inserting an indwelling catheter? 1) Avoid irrigation unless needed to relieve an obstruction. 2) Maintain an open system whenever possible. 3) Use clean technique when inserting a catheter. 4) Use the largest appropriate-sized catheter in order to prevent leakage.

1

The nurse has chosen the deltoid site to administer an intramuscular injection to an adult client. What size needle would the nurse use? 5/8 to 1 1/4 in (1.6 to 3.2 cm). 1 to 1 1/2 in (2.5 to 3.8 cm). 5/8 to 1 in (1.6 to 2.5 cm). 1 1/2 in (3.8 cm).

1 to 1 1/2 in (2.5 to 3.8 cm).

A client's MAR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action? Question 1 options: 1) Determine the compatibility of the two drugs by consulting clinical resources. 2) Recognize that it is not safe to mix two medications in one syringe. 3) Collaborate with the pharmacy to have one of the times changed. 4) Page the physician to determine whether the drugs can be mixed.

1) Determine the compatibility of the two drugs by consulting clinical resources.

The nurse is caring for a client who has two Jackson-Pratt drains following her bilateral mastectomy. When emptying a Jackson-Pratt drain, the nurse should prioritize what action? 1) Recompress the drain before replacing the cap. 2) Pin the drain to the client's gown after pulling the tubing taut. 3) Cleanse the area around the cap with alcohol for 30 seconds before removing it. 4) Don sterile gloves before manipulating the cap of the drain.

1) Recompress the drain before replacing the cap.

step by step/restraints

1)Explain rationale for use to the client and family. 2)Pad bony prominences. 3)Wrap the restraint around the client's ankle and secure it with hook-and-loop fastener straps. 4)Ensure that two fingers fit between the restraint and the client's skin. 5)Position limbs in normal anatomic position. 6)Secure restraints to the bed frame with quick-release knots.

Mr. Russell has been placed on fall precautions. What actions should the nurse take to keep the patient safe? (Select all that apply.) 1. Place the call bell within reach. 2. Provide non-skid socks for ambulation. 3. Instruct patient to call for assistance when out of bed. 4. Keep side rails up x 4 at all times. 5. Maintain bed in low position at all times.

1, 2, 3, 5

Which of the following are recommended techniques for reducing discomfort when injecting medications intramuscularly. Select all that apply. 1) Use two needles—one to remove the medication from the vial and a second one to inject the medication. 2) Insert the needle with a dart-like motion 3) Administer up to 4 mls in one injection per any site helps reduce needle stick anxiety. 4) Inject the medication into contracted muscle. 5) Select a needle of the smallest gauge and needle length that is appropriate for the site and solution to be injected. 6) Use the Z-track technique. 7) Inject the solution quickly so that it may be dispersed more easily into the surrounding tissue.

1, 2, 5, 6

as an indwelling urinary catheter? Select all that apply. Question 9 options: 1) Inspect the meatus for drainage and note the characteristics of the urine. 2) Perform care of the indwelling urinary catheter before perineal care. 3) Use an antiseptic cleaning agent or plain soap and water on a clean washcloth. 4) Put on sterile gloves before cleaning the catheter. 5) Clean 4-6 inches of the catheter, moving from the meatus downward.

1, 3, 5

How quickly would the nurse inject solution into an intramuscular site? 25 sec/mL of medication. 15 sec/mL of medication. 20 sec/mL of medication. 10 sec/mL of medication.

10 sec/mL of medication.

prealbumin

15-36 mg/dL a thyroxin-binding protein measured to evaluate the nutrition status of critically ill patients who are at high risk for malnutrition

Braden Scale for Predicting Pressure Sore Risk

19-23 not at risk 15-18 low risk 13-14 moderate risk 10-12 high risk Less than or equal to 9 very high risk

A nurse is caring for a female patient with an indwelling urinary catheter. Which of the following actions should the nurse take into consideration to reduce the client's risk of developing a urinary tract infection (UTI)? 1) Use clean technique when inserting the catheter. 2) Ensure that the catheter is removed as soon as possible. 3) Irrigate the catheter with sterile water once per shift. 4) Administer prophylactic antibiotics, as ordered.

2

A nurse is inserting a male client's indwelling urinary catheter. After preparing the sterile field and cleansing the client's meatus, the nurse realizes that he has brought the wrong sized catheter to the bedside. What is the nurse's best action? Question 12 options: 1) Place a sterile drape over the client's penis, obtain the right catheter and proceed with insertion. 2) Illuminate the client's call light and have a colleague bring the correct catheter to the bedside. 3) Teach the client the importance of not touching his penis or the sterile field and obtain the correct catheter. 4) Dismantle the sterile field, obtain a new dressing tray and the correct catheter, and then begin the procedure from the beginning.

2

The nurse has inserted a client's urinary catheter as ordered, but there has been no immediate flow of urine. What is the nurse's most appropriate action? Question 4 options: 1) Advance the catheter slightly, because a drainage hole may be resting against the bladder wall. 2) Have the client take a deep breath to relax the perineal and abdominal muscles. 3) Leave the catheter in place and reassess in 30 minutes. 4) Lower the head of the client's bed to increase pressure in the bladder area.

2

The nurse has received an order to remove a client's indwelling urinary catheter. Which of the following actions is appropriate when carrying out this order? Select all that apply. 1) Limit the client's fluid intake for 2 to 4 hours prior to removal. 2) The nurse may delegate this task to a licensed practical/vocational nurse 3) The nurse should remove the water from the balloon by withdrawing it with a syringe. 4) Strict aseptic technique must be used when removing the client's catheter. 5) The nurse may delegate this task to nursing assistive personnel or to unlicensed assistive personnel.

2, 3

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation? 1) Wound pouching 2) Penrose drain 3) Jackson-Pratt drain 4) Hemovac drain

2. penrose drain

A nurse is inserting a client's urinary catheter and notices a hole in one of the sterile gloves and that his hands are soiled. What would be the most appropriate action to take in order to maintain a sterile field? Question 11 options: 1) Finish the procedure and perform handwashing immediately afterward. 2) Finish the procedure, remove the damaged glove, and open new sterile gloves. 3) Stop the procedure, remove damaged glove, perform handwashing, and open new sterile gloves. 4) Stop the procedure, remove damaged glove, and open new sterile gloves.

3

A nurse who is right-handed is inserting a woman's indwelling urinary catheter. The nurse will use cotton balls and antiseptic solution to cleanse the woman's meatus and perineum. Which of the nurse's actions is most appropriate? Question 7 options: 1) Grasp a cotton ball with forceps in her left hand and spread the woman's labia with her right hand. 2) Perform hand hygiene between cleansing the woman's labia and inserting the catheter. 3) Use her left hand to spread the woman's labia and keep them spread until the catheter is inserted. 4) Insert the catheter with her left hand while supporting the woman with her right hand.

3

The nurse has inserted a woman's urinary catheter, but obtained no urine flowback. Closer examination reveals that the catheter is in the woman's vagina and not in her meatus. What should the nurse do? Question 8 options: 1) Remove the catheter, cleanse it thoroughly with antiseptic and reattempt insertion. 2) Remove the catheter, document this event and reattempt insertion in 30 to 60 minutes. 3) Leave the catheter in the woman's vagina and reattempt the sterile insertion of a new catheter. 4) Gently aspirate with a syringe to confirm that the catheter is in the vagina.

3

The nurse has received an order to catheterize a female client. Which of the following actions should the nurse perform? Question 2 options: 1) Lubricate 3 to 4 inches of the catheter tip before insertion. 2) Using both hands, hold the catheter near the tip and insert slowly into the urethra. 3) Once urine begins to drain, advance the catheter another 2 to 3 inches. 4) Advance the catheter until slight resistance is felt.

3

A client's MAR states that two medications are due at the same time, both of which are available in vials and are to be administered by injection. What is the nurse's most appropriate action? 1) Collaborate with the pharmacy to have one of the times changed. 2) Recognize that it is not safe to mix two medications in one syringe. 3) Determine the compatibility of the two drugs by consulting clinical resources. 4) Page the physician to determine whether the drugs can be mixed.

3) Determine the compatibility of the two drugs by consulting clinical resources.

A nurse is preparing to remove the staples from the donor vein site on a client's leg following cardiac surgery. Which of the following guidelines should inform the nurse's decision-making? 1) The nurse may delegate this task to nursing assistive personnel (NAP) or to unlicensed assistive personnel (UAP) 2) The nurse should remove the staples in sequence, beginning at the proximal edge of the wound. 3) The nurse should apply adhesive wound closure strips after removing staples. 4) The nurse should thoroughly irrigate the wound 15 to 30 minutes before the procedure.

3) The nurse should apply adhesive wound closure strips after removing staples.

A nurse has received an order to insert a urinary catheter into a female client. In preparation, the nurse asks if she has ever had an indwelling catheter and, if so, why and for how long. The nurse has performed which of the following actions? Question 5 options: 1) Assessed the client's risk of hemorrhage during insertion. 2) Gauged the client's risk of developing a urinary tract infection. 3) Assessed for most appropriate size of catheter to insert. 4) Assessed the possibility that the client has urethral strictures

4

A nurse is implementing the principles of surgical asepsis while inserting a client's indwelling urinary catheter. Which of the following actions should the nurse perform? Question 10 options: 1) Open sterile packages so that the first edge of the wrapper is directed towards you. 2) Consider the outer 3-inch edge of a sterile field to be contaminated. 3) Consider the outside of the sterile package to be partially sterile. 4) Hold sterile objects above waist level to prevent accidental contamination.

4

A nurse is performing a client's intermittent closed catheter irrigation and realizes that the tubing was not clamped before introducing the irrigation solution. What would be the nurse's best response to this situation? Question 13 options: 1) Wait 1 hour and repeat the irrigation. 2) Prepare to change the catheter. 3) Notify the primary care provider promptly. 4) Repeat the irrigation.

4

Which of the following is the preferred injection site for medications that are irritating and highly viscous? 1) Vastus lateralis 2) Deltoid 3) Dorsogluteal 4) Ventrogluteal

4) Ventrogluteal preferred and safest site for all adults, children, and infants... especially for medications that have larger volumes and are more viscous & irritating

lewy body dementia

A form of dementia characterized by an increase in Lewy body cells in the brain (balloon-like protein structures inside the neurons). Symptoms include visual hallucinations, momentary loss of attention, falling, and fainting.

Unstageable pressure ulcer

A full-thickness wound in which the amount of necrotic tissue, or eschar, in the wound bed makes it impossible to assess the depth of the wound or the involvement of underlying structures Even if it is suspected that a wound is a stage III or IV based on location and other characteristics, it is not possible to stage the wound until the necrotic tissue is removed, or debrided

stage II pressure ulcer

A partial-thickness wound that involves the epidermis and/or dermis but does not extend below the level of the dermis ◦ A Stage II pressure ulcer is shallow and superficial with a pink wound bed. ◦ Intact or ruptured blisters that are the result of pressure are also considered to be stage II ulcer

Alzheimer's disease (AD)

A progressive disease that destroys the brain's neurons (Tau protein clumps), gradually impairing memory, thinking, language, and other cognitive functions, resulting in the complete inability to care for oneself; the most common cause of dementia. - Increasing age: after age 65 years the risk for the disorders doubles every 5 years. - Family history increases an individual's chance of acquiring Alzheimer's disease. The strongest genetic risk involves the apolipoprotein e4 (APOE-e4) gene. - The same factors that increase the risk for heart disease also increase the risk for Alzheimer's: lack of exercise, smoking, hypertension, high cholesterol, and poorly controlled diabetes. - Studies have found an association between lifelong involvement in mentally and socially stimulating activities and reduced risk of Alzheimer's disease

Mini-Mental State Examination (MMSE)

A test that is used to measure cognitive ability, especially in late adulthood. 11 cognitive tasks that cover time orientation, place orientation, immediate recall, short-term memory recall, serial 7s, reading, writing, drawing, and verbal/motor comp (5-10 min). The lower the score, the more severe the impairment. Anything under 27 should be referred for further evaluation.

infected wound

A wound showing clinical signs of infection, including redness, warmth, and increased drainage that may or may not be purulent (contain pus)

chronic wound

A wound that fails to progress to healing in a timely manner, often remaining open for an extended period Chronic wounds commonly heal by secondary intention. In wounds that heal this way, new tissue must fill in from the bottom and sides of the wound until the wound bed is filled with new tissue. (no incision line) In some situations it is necessary to initially leave a wound open for a period of time after an injury. (ex: traumatic injury to the belly; afraid intestinal bacteria has contaminated the area if closed. Then in surgery they will clean it and close it). When a delay occurs between injury and closure, the wound healing is said to happen by tertiary intention. NOT COMMON.

colonized wound

A wound that has one or more organisms present on the surface, but when a swab culture is obtained there is no overt sign of an infection in the tissue below the surface

Acute wound

A wound that progresses through the phases of wound healing in a rapid, uncomplicated manner Wounds such as surgical incisions or traumatic wounds in which the edges of the wound can be approximated, or brought together, to heal are examples of acute wounds. An acute wound is said to heal by primary intention, which means that it tends to heal quickly and result in minimal scar formation. (edges of wound come back together and heal quickly)

prevention strategies

Abdominal binder Splinting Drains Hand Hygiene & Sterile Technique

Non-Opioids

Acetaminophen (Tylenol) Non-steroidal Anti-inflammatory Drugs (NSAIDs) Aspirin Ibuprofen (motrin) Ketoralac (Toradol)

barriers to pain control

Addiction Fear of side effects Fear of dependence Can't verbalize pain Don't have finances for meds No access to pharmacies Educational barriers

symptoms of dementia

Amnesia: short-term memory deficit Anomia: forgetting names of persons or things Anxiety: early on symptoms cause worry Agnosia: forgetting the purpose of familiar items Apraxia: forgetting how to perform activities Apathy: lack of concern for losses Aphasia: mute Sundowning: when the individual shows symptoms of acute confusion, disorientation, hallucinations, and mood swings during late day into night, often occurs. Clinical Presentation The onset of dementia can be subtle at first. Amnesia is commonly the first symptom experienced, though language, perceptual skills, reasoning, and personality are affected and may be more noticeable initially. This is especially true in individuals whose symptoms begin before age 65 years. Memory loss can begin with anomia, which is the forgetting of names of things and people. Despite being reminded, individuals with this condition often repeatedly forget the same information. Usually memory loss involves short-term memory before long-term memory. For example, persons with dementia often have difficulty remembering events from a few minutes ago or last week but can remember events from childhood. Individuals often can remember and reminisce about the most influential time of their life, such as a time when they were successful in their career or a parent of young children. Early in dementia, individuals can become disoriented and forget their way home or their original destination. They may not remember the day of the week or month. Reality orientation may frustrate the individual. The individual with dementia may demonstrate poor judgment, lack of ability to reason, and inability to think abstractly. For example, balancing a checkbook and managing finances become difficult tasks. Apraxia, which is difficulty in performing familiar tasks, occurs. The individual may forget how to get dressed properly or forget how to prepare a meal. Often self-hygiene becomes unmanageable. The individual often exhibits agnosia, which is forgetting the purpose of familiar items. He or she might exhibit this behavior in subtle ways, such as placing a toothbrush in a sugar bowl or a wrist watch in the refrigerator. Often the person with dementia exhibits rapid mood swings or personality changes, such as becoming paranoid, angry, or fearful for no apparent reason. It is important for significant others to realize that cognitive impairment and gradual losses of abilities can be extremely anxiety-provoking for the individual with early dementia. Individuals may express this anxiety in a number of ways, including withdrawing from social situations or becoming impatient and irritable when reminded of their lack of cognitive ability. Apathy or loss of initiative to become involved in activities is common. Individuals with dementia usually do not take part in exercise unless prompted and shown how to perform physical fitness activities. Persons with dementia commonly exhibit insomnia or hypersomnia because of lack of maintaining a proper sleep-wake cycle. Sundowning, when the individual shows symptoms of acute confusion, disorientation, hallucinations, and mood swings during late day into night, often occurs. Behavior can become erratic, violent, and difficult to manage. Sedation is frequently employed, which adds to the disruption of circadian rhythms. With severe dementia, individuals have difficulty recognizing relatives and caregivers. Individuals often also have problems with language. They may experience difficulty with finding the proper words and they often substitute inappropriate words, making sentences incomprehensible. With end stages of dementia, individuals often do not speak or perform activities.

Suspected deep tissue injury:

An area of intact skin that is purple or maroon or a blood-filled blister ◦ Like stage I ulcers, suspected deep tissue injuries may be difficult to detect in darker-skinned individuals. ◦ The true depth of tissue damage is not readily apparent on initial inspection; however, these injuries can progress rapidly, exposing deeper layers of tissue even if treated quickly and appropriate. (example: someone in a wheelchair who sits in one place all the time. tissue under the skin is compromised and it can become really bad really quickly).

A patient in the postoperative section of a same-day surgery center asks, "Why do you need to perform an assessment? I feel fine and am going home soon." What is the best response by the nurse? An assessment is done to complete the required paperwork. An assessment is done to assess compliance to preoperative instructions. An assessment is done to help the patient move in bed. An assessment assists with risk detection and control.

An assessment assists with risk detection and control.

Glasgow Coma Scale

An evaluation tool used to determine level of consciousness, which evaluates and assigns point values (scores) for eye opening, verbal response, and motor response, which are then totaled; effective in helping predict patient outcomes.

The nurse is administering an intramuscular injection of cortisone to a client. What action would the nurse take immediately following the injection? Recap the needle. Apply firm pressure with a dry gauze. Massage the site. Apply gentle pressure with a dry gauze.

Apply gentle pressure with dry gauze *After administering an intramuscular injection, the nurse would apply gentle, not firm, pressure at the site with a dry gauze. Applying light pressure would cause less trauma and irritation to the tissues. The nurse would not massage the site since massaging can force medications into subcutaneous tissue. The nurse would avoid recapping the needle to prevent accidental needlestick injury.

The nurse is performing a sterile dressing change. After donning sterile gloves, the nurse drops the dressing on the bed and does not have a replacement. What is the appropriate action at this time? Reapply the original dressing until a new one can be obtained. Ask the patient to press the call bell to summon a co-worker to obtain another dressing. Pick up the dressing and use the side that did not touch the bed. Remove gloves and go to the supply room to obtain more supplies.

Ask the patient to press the call bell to summon a co-worker to obtain another dressing.

Nurse's Role in Pharmacological Management

Assess for pain Administer pain medication Teach patient about medications Monitor for side effects Evaluate effectiveness of medication

The nurse is caring for an adult client on prescribed bed rest who repeatedly attempts to get out of bed despite instructions to remain in bed. Which initial interventions is appropriate? Contact the health care provider for a prescription to apply a waist restraint. Raise the side rails. Administer a prescribed dose of lorazepam. Assess for the need to urinate.

Assess for the need to urinate.

The nurse is caring for a combative, confused client that has been prescribed soft wrist restraints. When administering soft wrist restraints to the client, which action by the nurse is most appropriate? Secure the wrist restraints to the side rail. Delegate evaluations of the restraints at 2-hour intervals to unlicensed assistive personnel (UAP). Assess the client's need for fluids and toileting every 2 hours. Perform the client's activities of daily living (ADLs).

Assess the client's need for fluids and toileting every 2 hours. *Assessing fluids and toileting every 2 hours is necessary to maintain skin integrity and fluid balance. According to the UAP Nurse Practice Act, the duties of a UAP do not include performing assessments. The nurse should assist with the client's ADLs but allow the client the independence of performing as many as possible for oneself. The restraints should be secured to a non-movable part of the bed frame, and, thus, not to the side rail.

Explain the components of a basic assessment of cognition and differentiate normal from abnormal findings

Assessment of Consciousness is FIRST step ◦Wakefulness ◦Alertness ◦Appropriate response to conversation, questions and the environment During the interview: ◦Speech pattern (difficulty forming words or saying what is meant) ◦Appropriate responses to questions ◦Memory, Logic, Judgement Note pertinent health history ◦Brain trauma or disease, substance abuse, current medications, exposure to hazards (environmental or occupational) ◦Headaches, behavior changes, seizures, changes in memory or mental function Assessment of cognitive functioning occurs as part of the health history. It begins with assessment of consciousness because unless the patient is fully aware of self and the environment, other cognitive assessments may not be valid. The nurse observes the patient for wakefulness, alertness, and appropriate responses to introductions and to the environment as the health history interview is begun. The patient's speech pattern and content are noted, and memory, logic, and judgment are assessed while the interview progresses. Questions related to cognition included in the interview relate to history of intracranial disease or trauma; substance abuse; use of medications that can impair cognition; environmental or occupational exposure to hazards such as lead or insecticides; the presence of symptoms such as difficulty in forming words or saying what is meant, headache, behavior changes, or seizures suggestive of a brain disorder; unexplained emotional or behavioral changes; and any noticed change in memory or mental function. If any abnormalities are noted, a more specific cognitive assessment is performed. A family member who can assist with the history helps to provide greater understanding of the patient's cognitive level prior to hospitalization

How do you choose med/dose/route?

Based on assessment (history of pain management is important; be aware that you have biases!) Identify potential barriers Planned treatments/care Adverse effects? Previous intervention and effectiveness Be aware of bias / misconceptions

edema

Build up of fluid in the underlying tissues Secondary to poor venous return usually is most prominent in the lower extremities Stretched or glossy Pitting edema

blanching

Capillary Refill, Loss to return: immediate, <2 seconds Differentiate dilated blood vessels (blanch) from extra vascular blood (no blanch)

Problem-based history, skin assessment

Changes in skin condition and color New rash or lesion; changes in previous lesions Excessive bruising Loss of hair; changes in condition of nails Wounds slow to heal

Stage 1 pressure ulcer

Characterized by intact, nonblistered skin with nonblanchable erythema, or persistent redness, in the area that has been exposed to pressure Abnormal reactive hyperemia: The redness that occurs due to excessive vasodilation caused by pressure

Vesicle

Circumscribed, raised lesions, filled with serous fluid, less than 0.5 cm, and if they're greater than 0.5 cm they are called BULLAE - Chickenpox, poison ivy, second degree burn blisters

The nurse is preparing to administer an intramuscular injection to a client. Which statement accurately describes how to prepare the client's skin prior to the injection? Cleanse the area around the injection site with an antimicrobial swab using firm, circular motions moving outward from the site. Cleanse the area around the injection site with soap and water using firm, circular motions moving outward from the site. Cleanse the area around the injection site with an antimicrobial swab using firm, circular motions moving from the outside to the inside of the site. Shave any hair around the site and cleanse the site with an alcohol wipe using a brisk back and forth motion.

Cleanse the area around the injection site with an antimicrobial swab using firm, circular motions moving outward from the site.

What do we do for Lumbar Strain/Sprain

Cold therapy initially for a short period up to 48 hours Low level of activity Activities, particularly those involving lifting and extreme ROM of the spine, should be avoided. Heat therapy Anti-inflammatory agents; NSAIDS Muscle relaxants Intramuscular (IM) injections of muscle relaxants No manipulation of the affected area during the acute phase of the injury Supportive lumbosacral corset Physical therapy

skin assessment, interpreting findings

Color Elevation Pattern or Shape Size Location and Distribution (distribution is how widespread it is) Any Exudate

Mr. Russell experienced dysphagia and mild left-sided weakness following his stroke. For which additional symptoms of stroke should the nurse assess? (Select all that apply.) Communication difficulties Urinary incontinence Hearing loss Decreased peristalsis Sensory deficits

Communication difficulties Urinary incontinence Sensory deficits

When placing an indwelling urinary catheter, where should the nurse hold the catheter?

Correct Response: 2 to 3 in (5 to 7.5 cm) from the tip of the catheter Rationale:By holding the catheter 2 to 3 in (5 to 7.5 cm) from the tip, it allows for adequate control while decreasing risk of contamination. The catheter should not be held directly at the tip or at 1 in (2.5 cm) to facilitate insertion. Holding the catheter 4 to 5 in (10 to 12.5 cm) from the tip will not allow for good control and increases risk of contamination.

The nurse is caring for a female client with an indwelling urinary catheter. The nurse notes that the catheter is not draining. What is the correct action by the nurse?

Correct Response: Check the catheter tubing for kinks or twisting. Rationale:The catheter should first be checked for kinks or twisting that may be causing it not to drain. The catheter should not be pushed upward as this could cause damage to the urethra. The balloon should not be refilled with water as this could cause damage to the urethra. The catheter may need to be replaced if kinks or twisting are not evident. A condom catheter is only indicated for a male client.

The nurse is caring for a female client with an indwelling urinary catheter. The client reports sudden pain and urethral spasm. What is the best action by the nurse? Correct Response:Deflate the balloon, remove the catheter, and replace. Rationale:Sudden pain and urethral spasm can indicate that the catheter balloon may be lodged in the urethra. Balloon should be deflated, and the catheter should be removed and replaced. Pushing on the catheter or adding more water to the balloon can cause further urethral spasm and damage. Repositioning the client would not adequately address the problem. The best course of action is to remove the current catheter and insert a new one, using sterile technique.

Correct Response: Deflate the balloon, remove the catheter, and replace. Rationale:Sudden pain and urethral spasm can indicate that the catheter balloon may be lodged in the urethra. Balloon should be deflated, and the catheter should be removed and replaced. Pushing on the catheter or adding more water to the balloon can cause further urethral spasm and damage. Repositioning the client would not adequately address the problem. The best course of action is to remove the current catheter and insert a new one, using sterile technique.

The nurse is inserting an indwelling urinary catheter for a female client. Despite several tries, the nurse cannot get the catheter to advance into the bladder. What is the next action by the nurse?

Correct Response: Notify the client's health care provider. Rationale:If attempts have been made to advance the catheter, the nurse should stop and notify the client's health care provider. Drinking water or checking for tubing kinks would not affect catheter advancement. There is nothing to indicate that the client refused the procedure.

impaired tissue integrity

Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues.

The nurse is assessing a patient admitted with a venous stasis ulcer on the right lower extremity. What would the nurse expect to find when assessing the leg? Dark discoloration of the skin surrounding the wound site. Shiny skin with hair loss over legs, feet, and toes. Scaly rash between the toes with itchiness. Pale, white toes with decreased sensation.

Dark discoloration of the skin surrounding the wound site.

potential wound healing complicatiosn

Dehiscence: (de-HISS-ence) The partial or complete separation of the tissue layers during the healing process; usually occurs in connection with surgical incisions Evisceration: The total separation of the tissue layers, allowing the protrusion of visceral organs through the incision (like the alien in the movie - all edges of the wound are open - not seen all that often anymore due to internal surgery) "Healing ridge": Not really a complication! A 1-cm-wide ridge, or area of induration (redness) that can be palpated next to the incision line if a wound is healing properly; indicative of new collagen being laid down in the wound (you WANT this, it's normal, it's a complication if it's not present) Fistula: An abnormal connection between two internal organs or between an internal organ and, through the skin, the outside of the body Infection: Local or systemic infection due to bacterial invasion

Which is true about giving medication using the intramuscular route? Allows for a slower onset of the medication. Delivers medication into the muscle tissues. Can be painful. Is primarily used on people who lack sufficient muscle definition.

Delivers medication into the muscle tissues.

Which is true about giving medication using the intramuscular route? Allows for a slower onset of the medication. It is not painful. Delivers medication into the muscle tissues. Is primarily used on people who lack sufficient muscle definition.

Delivers medication into the muscle tissues. *These tissues have bigger blood vessels, and more of them, than subcutaneous tissue. This allows for a faster onset of the medication. Intramuscular injections can be painful, and the client should be prepared. Lack of sufficient muscle definition would be a challenge to intramuscular injections, not the reason for giving them.

alternatives to restraint

Determine whether a behavior pattern exists. Assess for pain and treat appropriately. Rule out physical causes for agitation. Involve family members. Reduce stimulation, noise, and light. Check environment for hazards and modify, if necessary. Use therapeutic touch. Assess and evaluate the effectiveness of restraint alternatives

individual risk factors for skin integrity

Diseases/conditions Poor peripheral perfusion - decreased oxygenation Malnutrition or obesity - Nutritional status Dehydration or edema Impaired mobility Immunosuppression - Consider infection Diabetes Exposure to irritants Radiation, temperature extremes, chemical or mechanical trauma, medical treatments Tissue trauma Friction, shearing, moisture, pressu

The nurse is holding the skin with the non-dominant hand prior to inserting the needle for an intramuscular injection. What is the recommended technique? Displace the skin using the Z-track technique by pulling the skin to one side 1 inch. Stretch the skin taut, taking care not to touch the injection site. Grasp and bunch the skin in the area surrounding the injection site. The skin at the site should not be disturbed prior to the injection.

Displace the skin using the Z-track technique by pulling the skin to one side 1 inch.

The nurse is completing an admission assessment on a patient admitted for impaired skin integrity. Which questions would be appropriate for the nurse to ask the patient? (Select all that apply.) Do you have any sores on your body? Do some areas of your skin seem warmer or colder than others? What kind of activities cause you to be fatigued? Have you used pads or special pants because you can't control your urine? Have you noticed any swelling on your feet, ankles, or fingers?

Do you have any sores on your body? Do some areas of your skin seem warmer or colder than others? Have you used pads or special pants because you can't control your urine? Have you noticed any swelling on your feet, ankles, or fingers?

cyst

Encapsulated fluid-filled or semisolid mass, extends into the dermis or subcu tissue - sebaceous cyst

The nurse is caring for a client with Alzheimer dementia who lives with an adult child at home and has started to wander. The adult child asks, "What can I do to keep my parent safe?" What are the best instruction(s) by the nurse? Select all that apply. Ensure the parent engages in regular exercise. Ensure that the parent's routine changes frequently. Provide frequent reorientation. Increase the parent's social interaction. Ensure the parent to take naps frequently.

Ensure the parent engages in regular exercise. Provide frequent reorientation. Increase the parent's social interaction.

neuropathic pain

Episodic or continuous pain that results from a nerve injury and persists even without painful stimuli. ex: Tumor, infection, toxicity from chemotherapy, neuropathy

A nurse is implementing measures as alternatives to using restraints. When implementing the client's plan of care, the nurse would anticipate the need to check on the client at which frequency? Every 1 to 2 hours Every 20 to 30 minutes Every 45 minutes to 1 hour Every 3 to 4 hours

Every 1 to 2 hours

drug tolerance

Expected side effect Physical adaptation to prolonged use Need larger doses to obtain same effect May be better to change to different medication * best way to treat is to change the medicine

Glasgow Coma Scale

Eye Opening Response • Spontaneous--open with blinking at baseline 4 points • To verbal stimuli, command, speech 3 points • To pain only (not applied to face) 2 points • No response 1 point Verbal Response • Oriented 5 points • Confused conversation, but able to answer questions 4 points • Inappropriate words 3 points • Incomprehensible speech 2 points • No response 1 point Motor Response • Obeys commands for movement 6 points • Purposeful movement to painful stimulus 5 points • Withdraws in response to pain 4 points • Flexion in response to pain (decorticate posturing) 3 points • Extension response in response to pain (decerebrate posturing) 2 points • No response 1 point

When removing contaminated sterile gloves, use non-dominant hand to grasp the opposite glove near cuff end on the outside exposed area. T/F

False

Managing Pain in Older Adults

False Assumption - Pain is a natural part of aging Expect Barriers Desire to be good pt Accustomed to dismissal of concerns Perception that no one wants to hear, won't make a difference * hard to manage b/c their liver metabolism slows down, and the nurse might be concerned that the medication might build up in their liver

palpation of skin in assessment

Feel skin for surface characteristics, temperature, and texture. Pinch skin for turgor Consider: Pressure areas, skin breakdown, skin odors, unusual position of leg folds, condition of axillae skin and the area under the breasts and any lesions or incision site

The nurse assesses a wound and documents it as stage III. What did the nurse observe when the wound was assessed? Partial-thickness loss of dermis presenting as a shallow open ulcer with a red/pink wound bed. Full-thickness tissue loss with exposed bone, tendon, or muscle. Intact skin with nonblanchable redness of a localized area. Full-thickness tissue loss, possibly with visible subcutaneous fat.

Full-thickness tissue loss, possibly with visible subcutaneous fat.

Stage III pressure ulcer

Full-thickness wounds that extend into the subcutaneous tissue but do not extend through the fascia to muscle, bone, or connective tissue ◦ Undermining: is an area of tissue loss present under intact skin, usually along the edges of the wound, forming a "lip" around the wound ◦ Tunnel or sinus tract: While similar to an undermining, it is a narrower passageway extending outward from the edge of the wound

inspection of skin

General color and condition of skin ◦ Lesions: location, size, shape, color, pattern, and characteristics (e.g., raised versus flat, dry versus exudate)

assessment of skin, general

General health history Past and current conditions Family history Allergies Current and recent medications History of skin disorder

PRN Administration of Medications

Goal: even, steady relief Drug will be scheduled on the basis of the drug's half-life Administer prn as if scheduled ATC "Rescue" doses may be needed for breakthrough pain (ex: giving morphine for a patient undergoing cancer therapy)

Sample questions for skin assessment

Have you observed any noticeable changes in the consistency color or texture of your skin, hair or nails recently? Could you describe the changes you have observed? Do you have any problems with perspiration, malodorous skin in the absence of perspiration?

reminisce therapy

Helping a patient with dementia relive past experiences Used in groups or individually Increasing levels of well-being and providing pleasure and cognitive stimulation

Gate Control Theory:

If pain impulses are stopped at the spinal cord gate, there are no transmissions to the brain and, therefore, no perception of pain. Significantly influenced current nonpharmacologic and pharmacologic interventions in pain management

three phases of wound healing

Inflammatory phase ◦ Lasts 3 to 5 days. ◦ Homeostasis develops; macrophages remove debris. Granulation phase ◦ Lasts 5 to 21 days. ◦ New blood vessels and tissue are formed. Maturation phase ◦ Lasts for months. ◦ Collagen fiber is remodeled; scar formation and contraction occur

full thickness injury

Injury of the dermis and deeper tissues. abdominal incision, Stage III and IV pressure ulcers

A nurse is caring for a client who is wearing a waist restraint. Which intervention by the nurse would be most appropriate to ensure that the client's breathing is not restricted? Keep a call bell within easy reach of the client. Insert the fist between the restraint and the client. Tie the restraint to the bed frame, not the side rail. Pad the client's bony prominences.

Insert the fist between the restraint and the client. *The nurse should insert one fist between the restraint and the client to ensure that the client's breathing is not constricted. Tying the restraint to the bed frame instead of the side rail and padding bony prominences are measures that help prevent injury, but they do not help prevent impaired breathing. Keeping a call bell within easy reach of the client would not help prevent impaired breathing.

A patient reports to the emergency department with complaints of abdominal pain. After assessing the patient's pain, the nurse should complete which assessment first? Auscultation of the abdomen Inspection of the abdomen Palpation of the abdomen Percussion of the abdomen

Inspection of the abdomen

partial thickness injury

Involves only the epidermis without injury to the underlying dermal or subcutaneous tissue. Stage I and II pressure ulcers, 1st and 2nd degree burns

Rete ridges, or the papillary dermis

Irregular, interconnected projections that extend up from the dermis and link with the epidermis above. These projections provide the "stick" that anchors these layers of skin together.

Mr. Russell is being discharged from the hospital following a mild stroke. What instruction would the nurse include in discharge education? Be sure to weigh yourself at the same time each day. You only need to take your medication when symptoms are present. A low-protein diet is necessary to maintain your health. It is important that you begin a smoking cessation program.

It is important that you begin a smoking cessation program.

Subcutaneous layer

Layer of adipose tissue, or fat, that, in addition to attaching the dermis to the underlying muscles and bone, delivers the blood supply to the dermis, provides insulation, and has a cushioning effect

Dermis

Layer of skin lying between the epidermis and the deeper subcutaneous layer; much thicker than the epidermis, although this thickness varies depending on the part of the body

purpuric lesions

Leaking of blood into tissues caused by broken vessels, clotting disorders. Dark skin: mm, compare side to side (will not blanch)

abnormal findings

Lethargic, obtunded Disoriented (note whether time, place or person) Flat expression Quality of speech Trouble recalling words Blocking Distorted speech Disconnected sentences Loose associations Confabulation

Titrate Dose to Provide Relief

Loading dose Consider history of opioids Be aware of physiologic changes in elderly Evaluate effectiveness of med / dose If requesting before due : inadequate dose or inappropriate interval

acute wound assessment and pressure ulcer assessment

Location Size (length, width, depth) Presence of Undermining or Tunneling Color (red, yellow, black) Cleanliness, Odor (clean, contaminated) Presence of wound drains (type) Presence of drainage and exudate ◦ Serous, serosanguineous, sanguineous, purulent Staging pressure ulcers ◦ Stages I, II, III, IV, nonstageabe

lumbar strain and sprain

Low back pain is one of the most common causes for patients to seek health care. The most common cause is lumbosacral strain and sprain. (L4-L5) Strains are defined as tears, either partial or complete, of the muscles and tendons. Muscle strains and tears most frequently result from a violent muscular contraction during an excessively forceful muscular stretch The L4-L5 and L5-S1 areas bear the highest loads and tend to undergo the most motion. Consequently, these areas are found to sustain the most spinal strain or sprain injuries. Sharp pain Tenderness Spasm over the posterior lumbar paravertebral spinal muscles or at the insertion of the muscle at the iliac crest Decreased, painful ROM If the injury is limited to a sprain or strain injury, then structural deformities and neurological symptoms are absent.

The nurse assesses the client and checks the medication prescription prior to administering an intramuscular injection. Which factor affects the choice of an intramuscular site? Client diagnosis. Medication volume. Size of needle used. Client gender.

Medication volume.

Side effects of narcotics

Medications Respiratory depression Sedation Nausea/vomiting Constipation Itching - indicates allergy

Adjuvant/Coanalgesic Medications

Medications that work synergistically with standard pain medications to enhance pain relief and treat side effects. Examples: - Antidepressants and anticonvulsants - Antiemetics, laxatives, stool softeners - NSAIDS, caffeine

Select analgesic effective for type / level of pain

Mild (pain score 1-3) Acetaminophen, NSAIDs Moderate (pain score 4-6) Ketorolac, Hydrocodone, Acetaminophen with codeine #3 Severe (pain score 7-10) Morphine, Hydromorphone, Fentanyl

Turgor & Mobility of skin

Mobility and Turgor shows: Elasticity of the skin - indication of dehydration 1.Pinch large fold of skin on anterior chest under clavicle. 2.Mobility is the ease of the skin to rise 3.Turgor is the ability to return to place when released. 4.Poor Turgor means severe dehydration As you age, the skin becomes less elastic, so older people might have a false positive turgor test. This is why we don't test on the back of the hand. We test just below the clavicle and under Too much edema means you can't grab the skin. If you're dehydrated the skin stays tented "Skin easily grasps and releases promptly" how to document "normal" turgor and mobility,

A nurse is administering an intramuscular injection to a client. Which best describes the nurse's recommended hand movements? Moves non-dominant hand to steady the lower end of the syringe, and dominant hand to the end of the plunger. Moves non-dominant hand to the base of the needle, and dominant hand to the end of the plunger. Moves non-dominant hand to the client's body, near the injection site, and dominant hand to the end of the plunger. Moves dominant hand to steady the lower end of the syringe, and non-dominant hand to the end of the plunger.

Moves non-dominant hand to steady the lower end of the syringe, and dominant hand to the end of the plunger.

vascular dementia

Multi-Infarct Dementia Caused by vascular pathology, blood clots in brain. Clot prevents flow to veins, and that tissue infarcts (brain cells dies). You can have multiple infarcts or a single infarct. Sporadic, and no set pattern. Deterioration of cerebral tissue in circumscribed area 2nd most common cause of dementia Accounts for 10-20% of cases of dementia M>F symptoms: similar to AD, but there are periods of plateau, seizure activity, personality usually doesn't change as much. Labile emotion see when the patient is very extreme ups and downs of mood or may be extremely high or low all the time (crying all the time) It is due to decreased blood supply to the brain and damages the cerebral cortex. Second most common cause of dementia. Mixed dementia is when have AD and cardiovascular dx neuroimaging ischemic lesions for diagnosis. Vascular Dementia. There are many causes of vascular dementia (also called multi-infarct dementia). Multi-infarct dementia is thought to be an irreversible form of dementia, and its onset is caused by a number of small strokes or, sometimes, one large stroke preceded or followed by other smaller strokes. The main subtypes of vascular dementia are: • mild cognitive impairment caused by multi-infarct dementia • vascular dementia caused by a strategic single infarct • vascular dementia caused by hemorrhagic lesions • mixed Alzheimer's and vascular dementia. Vascular lesions can be the result of diffuse cerebrovascular disease or focal lesions—usually both. Mixed dementia is diagnosed when patients have evidence of Alzheimer's disease and cerebrovascular disease, either clinically or based on neuroimaging evidence of ischemic lesions. Vascular dementia and Alzheimer's disease often coexist. Risk factors for vascular dementia include hypertension, smoking, hypercholesterolemia, diabetes mellitus, cardiovascular disease, and cerebrovascular disease. Arteriosclerosis and hypertension are the major causes of cerebrovascular disease.

In an acute care setting, addiction and substance abuse is...

NOT our primary concern. Our concern is assessment of pain based on what the pt says and treating the pain.

A nurse is caring for a cognitively impaired nonverbal patient on a medical-surgical unit. In what ways should the nurse assess the patient's pain? (Select all that apply.) Nonverbal pain assessment tool A verbal descriptor scale A pain estimate made by a family member The behavioral pain scale A numeric pain scale

Nonverbal pain assessment tool A pain estimate made by a family member The behavioral pain scale

The nurse notices that the patient who had surgery earlier in the day is now pale and restless with low blood pressure, tachycardia, and tachypnea. What is the nurse's priority action based on these findings? Complete an assessment of the patient's pain. Encourage the patient to cough, turn, and take a deep breath. Notify the provider of assessment findings immediately. Document the expected findings.

Notify the provider of assessment findings immediately. *A patient who is pale and restless with low blood pressure, tachycardia, and tachypnea could be experiencing hemorrhage or hypovolemic shock. The nurse should immediately report these assessment findings. The other answer choices may be appropriate nursing interventions, but they are not the priority for this patient at this time.

A postoperative patient begins to complain of pain, redness, and swelling in her left calf. What should the nurse do for the patient? Provide instruction on leg exercises. Notify the surgeon immediately. Reassure the patient of this normal finding. Massage the affected extremity.

Notify the surgeon immediately. *Postoperative patients are at risk for thrombophlebitis manifested by pain, redness, or swelling in a lower extremity. The nurse should notify the surgeon immediately. The risk for the patient is a part of the clot breaking off and traveling to the lung, causing an embolus. The leg should not be massaged or exercised at this time. The nurse would not reassure the patient that it is a normal finding.

Clean wound

One in which there is no infection and the risk for development of an infection is low

Stratum corneum

Outermost of the epidermal layers, made up of flattened dead cells The middle three layers, each of which is one to five cells thick, provide for a transition from the stratum germinativum to the stratum corneum.

The nurse is caring for an older adult with dementia for whom the health care provider has prescribed a waist restraint. What should the nurse do immediately before applying the waist restraint? Use a quick-release knot. Remove personal protective equipment (PPE). Tie the knot tightly. Pad bony prominences.

Pad bony prominences. *Immediately before applying the waist restraint, the nurse should assess and pad bony prominences that may be affected by the waist restraint. The nurse should use a quick-release knot after applying the restraint. The restraint should be not tied tightly, but snugly. Securing the restraint too tightly could impair the client's breathing. The nurse should remove PPE after applying the restraint.

breakthrough pain

Pain that occurs between doses of pain medication

somatic pain

Pain that originates from skeletal muscles, ligaments, or joints.

Acute

Pain that results from an acute injury, has a rapid onset and short duration, and subsides when the injury is healed. ex: Trauma, surgery, labor, acute disease

The nurse applied restraints to a client 2 hours ago for aggressive actions. What action does the nurse perform? Reassess cognitive status and the need to continue the restraints. Perform a circulation check and offer toileting and hydration. Instruct the client that improved behavior results in restraint removal. Ensure an as needed restraint prescription is in place and signed.

Perform a circulation check and offer toileting and hydration. *Restraints must be removed at least every 2 hours to facilitate circulation and allow the client to go to the bathroom and get fluids. Restraints are not used on an as needed basis but are used for a 24-hour period with breaks only for basic needs, like toileting. Even if the client suddenly seems calm, removal of the restraints is not permitted. Once this is done, a new prescription must be obtained and there are legal issues to consider. Bargaining with the client for restraint removal is not an acceptable nursing action. Restraint use is a safety measure, not a punishment.

The nurse is administering an intramuscular injection of the hepatitis B vaccine to a client. At what angle would the nurse insert the needle? At a 60-degree angle. Horizontal to the skin. At a 30-degree angle. Perpendicular to the skin.

Perpendicular to the skin.

Chronic pain

Persistent pain that lasts longer than 6 months, may be episodic or continuous, and may lead to disability. This is pain your body gets used to. ex: Arthritis, fibromyalgia, neuropathy

collaborative interventions for skin

Pharmacotherapy ◦ Antibiotics, steroids, emollients, chemotherapy agents Phototherapy Surgical interventions ◦ Excisions, debridement, skin grafts Wound care Nutritional support ◦ Protein, vitamin A, and vitamin C are critic

nociceptive pain

Physiologic pain that results from nociceptor stimulation in response to an injury or tissue damage. visceral pain is part of this. Usually ACUTE. ex: Surgery, inflammation, trauma

The nurse is administering an intramuscular injection to a client using the ventrogluteal site. How would the nurse locate the site? Place the palm on the anterior superior iliac spine and the index finger toward the greater trochanter. Place the palm on the greater trochanter and the index finger on the anterior superior iliac spine. Place the palm on the anterior superior iliac spine and the index finger toward the vastus lateralis. Place the palm on the vastus lateralis and the index finger toward the greater trochanter.

Place the palm on the greater trochanter and the index finger on the anterior superior iliac spine.

non-pharmacological pain interventions

Positioning Application of Heat or Cold Therapeutic Touch (after consent) Massage (after consent) Yoga Herbal remedies Meditation Transcutaneous Electrical Nerve Stimulation (TENS) Imagery Acupuncture Biofeedback Hypnosis Distraction

Nursing Attitudes and Practices Related to Pain

Practicing on the basis of "feeling" vs evidence Doubting vs believing the client in pain Patient as drug seeking vs drug needing Fear of respiratory depression → under- dosing PRN vs around-the-clock

The nurse is reviewing the patient's laboratory results. Which lab test most accurately represents current nutritional status? Albumin Iron Calcium Prealbumin

Prealbumin

A nurse is preparing an inservice program for a group of staff nurses about ways to minimize restraint use on the unit. The nurse plans to address the risks associated with physical restraint use. Which risk would the nurse include? Select all that apply. Kidney stones Pressure injuries Delirium Contractures Falls

Pressure injuries Delirium Contractures Falls

how to treat cognitive impairment?

Provide appropriate nursing AND collaborative interventions to decrease the symptoms AND impact of cognitive impairment *think safety*

The nurse is caring for a stroke patient with mild dysphagia. What would be an appropriate nursing intervention for this patient in order to minimize risk for injury? (Select all that apply.) Providing a 30-minute rest period prior to mealtimes Positioning patient upright in chair if not contraindicated Educating the patient about the importance of alternating liquids and solids Placing food in an easily accessible position Providing mouth care immediately before meals

Providing a 30-minute rest period prior to mealtimes Positioning patient upright in chair if not contraindicated Educating the patient about the importance of alternating liquids and solids

opioids

Pure agonists Morphine Fentanyl Hydrocodone Codeine

The nurse removes a dressing and assesses yellow, foul smelling drainage. How would the nurse document this finding? Serous Serosanguineous Purulent Sanguineous

Purulent

Nodule

Raised solid mass with defined borders, extends into dermis or beyond, deeper and more solid than a papule - Lipomas, squamos cell cancers

A nurse rounding on a patient in the postanesthesia recovery unit notices the bandage covering the incision site shows evidence of bleeding through the dressing. What is the priority action that the nurse should take? Change the dressing. Document this finding. Reinforce the dressing. Check the patient again in one hour.

Reinforce the dressing.

The nurse is administering an intramuscular injection in the deltoid site when the client pulls away from the needle before the medication is fully injected. What should the nurse do next? Replace the needle on the syringe and administer the remaining medication in another site. Use the same needle and continue with administration in the same site Use the same needle and administer the remaining medication in a different site Replace the needle on the syringe and administer the remaining medication in the same site.

Replace the needle on the syringe and administer the remaining medication in another site.

A nurse is caring for a patient who had an appendectomy. The patient is having difficulty breathing, is nauseated, and does not want to use the incentive spirometer because it hurts the incision. What is the nurse's priority intervention at this time? Call the provider to report findings. Reposition the patient in bed to improve breathing. Aggressively treat the nausea. Teach the patient to splint the incision when using the incentive spirometer.

Reposition the patient in bed to improve breathing.

Contaminated wound

Results from a break in sterile technique during surgery

SOCRATES Pain Assessment

S = site (Where is the pain located?) O = onset (When did the pain start? Was it gradual or sudden?) C = character (What is the quality of the pain? Is it stabbing, burning, or aching in nature?) R = radiation (Does the pain radiate anywhere?) A = associations (What signs and symptoms are associated with the pain?) T = time course (Is there any pattern to when the pain occurs?) E = exacerbating/relieving factors (Does anything make the pain worse or lessen it?) S = severity (On a scale of 0 to 10, what is the intensity of the pain?)

physiology of pain

Signals from the nociceptors travel along two types of afferent (sensory) nerve fibers: A-delta fibers, which are large-diameter, myelinated fibers with rapid conduction that cause sharp, acute pain, and C fibers, which are smaller, unmyelinated fibers with slow conduction that cause a diffuse, dull, and longer-lasting pain.

pustule

Similar to vesicle, but they contain pus instead of serous fluid, most commonly infected - Impetigo, acne

The nurse is preparing to administer a vaccination to an adult in the deltoid site. In what position would the nurse place the client? Sitting. Prone. Lying laterally. Lying supine.

Sitting

primary prevention

Skin hygiene Adequate nutrition Avoidance of excessive sun exposure Burn safety precautions Dermal ulcer prevention

Tumor

Solid mass that extends through subcu tissue, may have undefined borders, not always cancerous. lipoma, cancerous tissue

papule

Solid raised lesion with defined borders - Warts, psoriasis, actinic keratosis *PLAQUE - Solid, raised lesion with distinct borders. Variety of shapes, often associations with secondary features - same as papule by if it is GREATER than 0.5 cm it is called a plaque

a nurse identifies that a patient's pressure ulcer has just partial thickness skin loss involving the epidermis and the dermis. What stage pressure ulcer is this?

Stage II

which stage pressure ulcer requires the nurse to measure the extent of undermining?

Stage III

Lumbar physical examination

Standing: full ROM; flexion, extension, lateral flexion, and rotation Prone position: palpate the paravertebral musculature, areas of muscle spasm, and the location of any point tenderness, if present. Supine: elicit the straight leg-raising sign. The straight leg-raising test helps to evaluate disc involvement, sciatica, or a neurological deficit. A positive straight leg-raising test indicates sciatica. In addition, the clinician should try to elicit a positive Patrick sign. A positive Patrick test, also called a FABER test, points to a sacroiliac joint inflammation, but this test should be negative in lumbosacral sprains and strains.

The nurse is withdrawing insulin from a vial to prepare an injection for a client. After removing the metal cap on the vial, what would be the nurse's next step in the procedure? Remove the rubber top and insert the syringe into the vial. Hold the vial on a flat surface and pierce the stopper with the needle tip. Plunge the needle of the syringe into the hole in the rubber cap. Swab the rubber top with an antimicrobial swab and allow it to dry.

Swab the rubber top with an antimicrobial swab and allow it to dry.

vital signs are part pain assessment

T, HR, BP, R - these often show evidence of the body's response to pain.

A patient appears restless, and is grimacing and moaning after surgery. The patient denies the need for pain medication at this time. What is the best response by the nurse? Call the charge nurse to administer pain medication. Teach the patient about the importance of effective pain management. Administer pain medication to the patient. Continue with the physical assessment.

Teach the patient about the importance of effective pain management. *When left untreated, pain can have negative consequences that could impact health. The best response by the nurse is to teach the patient why effective pain management is important. The nurse should document the assessment of the patient's pain, educating about pain management, and the patient's response to pain medication after discussion with the patient. It is inappropriate to give pain medication to someone who is refusing it.

Mini-Cog Test

Test for dementia that asks clients to draw a clock face indicating a particular time

A nurse cares for a client wearing a waist restraint. Which client action causes the nurse to change restraint types? The client has preexisting pressure injuries and skin breakdown on bony prominences. The client has frequent and large episodes of stool and urinary incontinence. The client has a high risk of injuries and falls related to confusion and medications. The client continually tries to move from head of the bed toward the foot of the bed.

The client continually tries to move from head of the bed toward the foot of the bed. *Research suggests that waist restraints pose the same risks for asphyxial death as vest restraints. When the client is very mobile in the bed or chair, the risk for asphyxiation increases. The nurse should pad skin and bony prominences that will be covered by the restraint to reduce friction and pressure to skin and underlying tissue. Restraints ground a client's center of gravity, thus helping to prevent injuries and falls such as rolling off a stretcher or falling out of bed. Because the nurse should be following the removal schedule (every 2 hours), the client is at less risk for incontinence and dehydration because these needs are being met every 2 hours.

The nurse has just finished injecting a medication intramuscularly, and needle is still in the client's arm. Which is the correct immediate next step? Wait 10 seconds and then withdraw the needle Move the syringe slightly left and right to facilitate absorption of the medication Withdraw the needle immediately Gently pull back on the syringe plunger and observe for blood in the syringe

The immediate next step would be to wait 10 seconds and then withdraw the needle. Waiting allows the medication to begin to diffuse into the surrounding muscle tissue. *Aspiration, or pulling back on the plunger to check that a blood vessel has been entered, is not necessary nor recommended. Moving the syringe could cause damage to the tissues and inadvertent administration into incorrect area, so this should not be done.

Pain tolerance

The intensity or duration of pain that a patient is able or willing to endure. *A patient's past pain experience influences their tolerance. So does their exposure to opioids (makes their tolerance less)

The nurse received an order for a postoperative patient in an acute care facility. The order stated: Morphine, 1-6 mg IV every 2 hours as needed for pain. What should the nurse question about this order? An "as needed" dosing interval Nothing, because this is an expected order for a postoperative patient. Intravenous morphine for a postoperative patient The medication range of 1-6 mg

The medication range of 1-6 mg * Pain medication orders should not include a dosing range and should be questioned. Intravenous morphine is acceptable for a postoperative inpatient. It is also acceptable for pain medication to be ordered as needed.

A patient is at the hospital being prepared for a surgical procedure. Which of the following is a priority for the nurse to teach at this time? How to use the incentive spirometer after surgery The plan for following up with the surgeon after discharge The plan for assessing and treating postoperative pain How to clean the wound once the bandage is removed

The plan for assessing and treating postoperative pain While all of the answer choices are important, the plan for assessing and treating postoperative pain is the priority at this time. The patient may be anxious about experiencing postoperative pain, and discussing the plan of care could decrease anxiety. Teaching about the incentive spirometer after surgery is important to do preoperatively, but is not likely to be causing the patient anxiety at this time. The other answer choices can be accomplished after surgery.

Pain threshold

The point at which the brain recognizes the stimulus as pain. *as a nurse, this means pain is unique to everyone

Stage IV pressure ulcer

This wound is deeper than a stage III pressure ulcer and involves exposure of muscle, bone, or connective tissue such as tendons or cartilage. Hard to heal! Bone can be infected, and bone infections are hard to heal. ◦ The depth of the wound, particularly if the bone is palpable, makes osteomyelitis, or an infection of the bone itself, likely

Pain med evaluation * important *

Time intervals for reassessment are patient-specific and depend on the route of administration: Nonpharmacologic techniques: 30 to 60 minutes postintervention (b/c these might not be working that well!) IM, SC, or PO administration: 30 to 60 minutes postintervention Transdermal administration: 12 to 16 hours postintervention (this is at the peak of its onset) IV or sublingual administration: 15 to 30 minutes postintervention (must check soon for respiratory depression)

Mr. Russell has an order for vital signs and neurochecks every four hours. Which assessment findings, if made by the nurse, would indicate potential neurologic compromise? (Select all that apply.) Unsteady gait Difficulty swallowing Unequal pupils Decreasing level of consciousness Left-sided weakness

Unequal pupils Decreasing level of consciousness

The nurse is caring for a client with bilateral soft extremity restraints. The client is confused and tried to get out of bed, pulling out the urinary catheter which has been reinserted. Which is the best action by the nurse? Restrain the client. Check the client every 30 minutes. Ask a family member to sit with the client. Use a safety monitoring device.

Use a safety monitoring device. *A bed exit safety monitoring device can allow the client to feel independent, while alerting nursing staff if the client needs assistance. Restraining the client takes away independence and can increase agitation and confusion. Asking a family member to sit with the client may help calm the client, but inappropriately transfers the nurse's responsibility to the family member. Checking on the client every 30 minutes is insufficient, because the client could fall and sustain injury during the unobserved intervals.

(PCA) Self administered - only when feeling pain

Used for IV, subq, epidural Opioids Delivery device / infusion pump vary Settings: - Loading dose: bigger than the rest of the doses, first dose - Bolus dose: amount of med they get when they hit their button (ex: 0.2 g morphine every time they push the button, with a per-hour limit) - Lockout interval: timeframe between when the self-administer button cuts off, such as every 6 min.) - Basal rate: constant dose of the narcotic through the IV separate from the bolus dose. sometimes pts get a basal rate and some do not.

The nurse administering an intramuscular injection to a client divides the thigh into thirds, horizontally and vertically to locate the site. What injection site is the nurse using? Greater trochanter of femur. Vastus lateralis site. Ventrogluteal site. Deltoid muscle.

Vastus lateralis site.

The nurse is assessing a patient using the Glasgow Coma Scale. Which of the following are components of that scale? (Select all that apply.) Respirations Brainstem reflexes Verbal response Eye opening Motor response

Verbal response Eye opening Motor response

Tertiary intention:

Wound healing is delayed and occurs when the wound that was previously open is now closed. This process is usually associated with large infected and contaminated wound

Secondary intention:

Wound margins are not well approximated; larger wound area requires the formation of granulation tissue to fill in the gap. A longer period of time is needed to heal

Primary intention:

Wound margins are well approximated; examples include laceration and surgical incision. This process has the most rapid healing.

Sara Lin is concerned about pain management when she transitions to oral pain medication. What should the nurse include in the teaching? (Select all that apply.) You can use complementary therapy in conjunction with pain medication. PRN medications are given as needed. You should limit pain medication so you do not become addicted. Please ask for pain medications before the pain is severe. You can administer your own oral pain medication as needed.

You can use complementary therapy in conjunction with pain medication. PRN medications are given as needed. Please ask for pain medications before the pain is severe.

penrose drain

a flat, thin, rubber tube inserted into a wound to allow for fluid to flow from the wound; it has an open end that drains onto a dressing

Visceral pain

a poorly localized, dull, or diffuse pain that arises from the abdominal organs, or viscera

petechiae

a small red or purple spot caused by bleeding into the skin.

adjunctive therapy

a treatment used together with the primary treatment

nursing diagnosis for delirium

acute confusion pt will return to baseline cognition level Medications is the most common reason for acute delirium

Preemptive

administration of medications prior to a painful event in order to minimize pain.

Stratum germinativum

also known as the basal cell layer, the deepest live layer of the epidermis that produces new epidermal skin cells and is responsible for growth. (the only single layer of cells, but very active)

perception of pain

awareness of pain. Perception results from the interaction of transduction, transmission, modulation, psychologic and other characteristics of the individual. All four steps along the pain pathway are tied together by the Gate Control Theory

Ecchymosis

bruise

categories of cognitive impairment

delirium neuro-cognitive disorders (dementia) cognitive impairment not dementia focal cognitive disorders intellectual disability learning disability

Delirium vs Dementia

delirium happens quickly (days), dementia is progressive and irreversible. delirium is fluctuating, dementia is progressive. delirium is an altered state of consciousness, but dementia pts can be alert psychomotor effects can be increased or decreased with delirium, but dementia pts can be normal delirium is fully reversible, dementia is not

A nurse is administering an adult client's ordered antipsychotic drug intramuscularly. What would be the most appropriate site for administration? 1) Vastus lateralis 2) Scapula 3) Biceps brachii 4) Deltoid

deltoid The deltoid and ventrogluteal sites are more appropriate for adults than the vastus lateralis. The scapula is a site for an intradermal injection. The biceps brachii muscle is not used for intramuscular injections.

The nurse is caring for an adult who requires IV fluids but continues to pull at the IV site and tubing. The adult child tries to calm the client, without success. Which short-term restraints should the nurse use to control the adult's movement during the procedure? waist restraint extremity restraint elbow restraint mummy restraint

extremity restraint

Primary Lesion: Macule

flat; cannot be palpated - freckles!

Jackson-Pratt drain

hollow bulb-like device used to collect drainage

common cause of delirium

hypoxia from infection such as UTI (as opposed to fever)

what number on the Glasgow coma scale would make you think a person isn't the most reliable in an interview?

if it's less than 15, you need to explain where those points were lost

why would pain cause pneumonia or atelectasis?

if you're in such pain that you can't take a deep breath or sit up straight, you'll have consolidation of fluids and you won't want to mobilize your diaphragm.

consequences of impaired tissue integrity:

impaired thermoregulation balance infection fluid and electrolyte balance - skin protects and contains fluid for the body safety, such a risk of injury or falls - if you have peripheral neuropathy, then you have no sense of feeling in your skin. pain - pain sensors are located in the skin impaired body image

wheal

irregularly shaped, slightly elevated area; small, localized area of edema on the surface of the skin; typical of allergic reactions (hives; insect bites)

for the elderly, you'll give (less/more) for pain killer?

less (b/c of their liver metabolism)

drug withdraw

more than just a physical need - emotional, psychological. often a lower pain tolerance if it's opioid withdraw

Multimodal therapy for pain

more than one means for controlling pain, including meds that have more than one ingredient

physical dependence

occurs in everyone over time Abrupt cessation causes drug-specific withdrawal syndrome - not with just opioids! Also with steroids, beta-blockers, antidepressants, nasal sprays.

differences between delirium and dementia

onset course consciousness attention

Epidermis

outermost layer of skin, thinnest

radiating pain

pain felt at the site of tissue damage and in nearby areas, ex: chest pain radiates down the limb

psychogenic pain

pain for which no physical cause can be identified

phantom pain

pain or discomfort felt in an amputated limb

Nociceptors

pain receptors, which are the free endings of afferent nerve fibers, which are sensitive to thermal, mechanical, or chemical stimuli.

referred pain

pain that is felt in a location other than where the pain originates. ex: gallbladder issues, pancreatic issues you feel in the neck

modulation of pain

process of dampening or amplifying the pain-related neural signals. takes place in the dorsal horn of the spinal cord, but probably also multiple other levels as well. Rich arrays of opioid receptors (mu, kappa, and delta) are present in the dorsal horn * Once pain is recognized, the brain can change the perception of pain by sending inhibitory input to the spinal cord to impede the transmission through a process called modulation

A-delta fibers

quick, sharp pain

Match the wound to the healing process - primary intention, secondary intention, tertiary intention?

secondary intention. (*No approximated edges, no surgery that caused this.) *tertiary is a DELAYED wound after surgery.

Which position should the nurse avoid placing the patient if the patient is emaciated? 1. Thirty degree lateral 2. side-lying 3. supine 4. prone

side-lying

Clean contaminated wound

similar to a clean wound, but because the surgery involves organ systems that are likely to contain bacteria, the risk for infection is greater.

c fibers

slow conduction, dull, longer-lasting pain

ABCDE screening for malignant melanoma Discussion Questions: 1. What does ABCDE stand for? 2. Who should have ABCDE screening? 3. How often should it be performed?

specific to skin cancer screening: Asymmetry Border Color Evolving Everyone should get it - performed monthly

Which wounds would heal by primary intension? Select all that apply: cut by a kitchen knife surgical incision pressure ulcer excoriated perianal area abrasion of the skin

surgical knife surgical knife NOT abrasion b/c you have to have a well-approximated edge, you have to have at least more than a superficial wound

Confusion Assessment Method (CAM)

tests for delirium FEATURE 1: evidence of acute change in mental status FEATURE 2: Inattention, difficulty focussing attention, keeping on track (feature 1 and 2 must be present) **AND** either FEATURE 3: disorganized thinking or FEATURE 4: altered level of consciousness. "Hallmark Signs" - Agitation and restlessness is an early sign sometimes you will notice the patient picking at his or her gown. - Misperceptions - they may think your trying to hurt them when you are actually trying to help them. (May need family input sometimes very hard to determine if they are having acute confusion if they are chronically confused. You will need assistance in differentiating there normal from abnormal. So listen to the family.) - Change in LOC may see a decline where they go from drowsy lethargic to obtunded. This is a snap shot from the confusion assessment model a reliable tool to use. Impairment of consciousness & attention Sudden Change: Attention impaired Agitation/restlessness Disorganized speech Misperceptions Hallucinations/paranoia Changes in LOC Inattention: Easily distracted, trouble keeping track of what is said, or quiet/subdued. Objective assessment: ask patient to spell "world" backward, recite seven digits forward or five digits in reverse, count backward from 20 to one, or recite the days of the week or months of the year backward. Feature 3, disorganized thinking, can be assessed by asking standard orientation questions. For example, "Do you know what year it is? What season we're in? Do you know today's date? Do you know what month it is? About what time is it now? Where are we?" Disorganized thinking makes answering these question difficult, eliciting evasive, rambling, or irrelevant conversation; an illogical flow of ideas; paranoid statements; or evidence of hallucination. (Remember that in patients with dementia, such signs may be a part of baseline status.) Feature 4, determined by behavioral assessment, is altered level of consciousness. If the patient's level of consciousness is determined to be anything other than alert (vigilant or restless, lethargic, or comatose) the patient is considered positive for this feature. Restlessness, agitation, and fearfulness are symptoms of hyperactive delirium, while lethargic states may reflect hypoactive delirium. In mixed delirium, patients fluctuate among hypoalert, hyperalert, and normal levels of consciousness. Clinicians frequently don't recognize hypoalert states, often because of their subtle presentation.

The nurse is caring for a client who has been prescribed extremity restraints. Which action must be documented by the nurse? the type of personal protective equipment used by the nurse during restraint application the alternative measures attempted before applying the restraints a detailed description of the restraint application process a verbal prescription for the restraints, renewed every 48 hours

the alternative measures attempted before applying the restraints

Define and describe the concept of cognitive impairment

the diminishment in visual and verbal learning and memory, inability to pay attention, decreased speed of information processing, and inability to engage in abstract reasoning, any or all of which may be found in different psychotic disorders

transduction of pain

the process by which afferent nerve endings participate in translating noxious stimuli (like a bee sting) into nociceptive impulses. There are three types of primary afferents: A-beta, A-delta, and C fibers. Of these, the A-delta and C fibers are involved in nociception. In the process of transduction, the body converts the energy from the pain stimuli into electrical energy through nociceptors at the place of tissue injury. Tissue injury initiates the release of chemicals called: Neurotransmitters, which are inflammatory substances that are released into the extracellular space as a result of tissue damage

transmission of pain

the process by which impulses are sent to the dorsal horn of the spinal cord, and then along the sensory tracts to the brain. The primary afferent neurons are active senders and receivers of chemical and electrical signals. Their axons terminates in the dorsal horn of the spinal cord where they have connections with many spinal neurons. tl;dr: movement of pain impulses from the periphery to the spinal cord & then to the brain

tissue integrity

the state of structurally intact and physiologically functioning epithelial tissues such as the integument (including the skin and subcutaneous tissue) and mucous membranes.

Gate Control Theory

the theory that the spinal cord contains a neurological "gate" that blocks pain signals or allows them to pass on to the brain. The "gate" is opened by the activity of pain signals traveling up small nerve fibers and is closed by activity in larger fibers or by information coming from the brain. longer explanation: a popular model of pain modulation is the Gate Control Theory. It proposed that the existence of an endogenous ability to reduce or increase the degree of perceived pain through modulation of incoming impulses at a gate located in the dorsal horn of the spinal cord. The gate acts on signals from the ascending and descending systems and weighs all the inputs. The integration of these inputs from sensory neurons, the segmental spinal cord level, and the brain determines whether the gate will be opened or closed, either increasing or decreasing the intensity of the ascending pain signal

What component of orientation is lost first? (person, place, time)

time, orientation to person is usually last.

Four physiological processes of normal pain

transduction, transmission, perception, modulation

The nurse is preparing to administer a waist restraint to a client in a wheelchair. Which method of securing the restraint is appropriate? tying the restraint behind the chair tying the restraint in front of the chair tying the restraint under the chair tying the restraint to the side rail of the chair

tying the restraint behind the chair

Factors that lead to the development of wounds and delays in wound healing include:

vascular disease, diabetes, malnutrition, medications, excessive moisture, external forces, and the aging process

somatosensory cortex

where the intensity, quality of pain is centered

general management for cognitive impairment

§Promoting general health and comfort §Reorientation §Pain management §Regulation of stimulation §Behavioral management §Sensory aids §Caregiver support

Dressings

◦ Keep wound free of contamination ◦ Absorb drainage ◦ Protect periwound tissue ◦ Treat infection ◦ Aid in debridement ◦ Many different types of dressings: ◦ Gauze, nonadherent dressings, occlusive, semiocclusive, hydrocolloid, hydrogel, and alginate are applied. ◦ Vacuum-assisted systems are use

Normal findings

◦Alert and awake ◦Oriented to person, place and time ◦Affect: animated, happy, appropriate to the situation (describe) ◦Quality of speech ◦Effortless ◦Fluent ◦Articulate ◦Moderate pace

The nurse considers applying restraints to an agitated client. Which actions does the nurse take? "Assess the client for existing injuries to the wrists and hands." "Dim the lights and speak softly about something the client enjoys." "Call a family member to come and sit with the client." "Ensure the client cannot reach any objects in the room."

"Dim the lights and speak softly about something the client enjoys."

The nurse is teaching a client with diabetes to withdraw insulin from a vial when the client and the client asks why it is recommended to recap the needle after withdrawing the medication. What is the best response by the nurse?

"Recapping the needle maintains sterility of the needle before injecting." * The needle should be recapped after withdrawing medication to maintain the sterility of the needle prior to injecting. Recapping the needle will not prevent medication from leaking out. Recapping the needle will not prevent contamination of the syringe. If a needle has been used only to draw up medication, there is no risk of contamination from bodily fluids, so a needle stick is not a concern. Never recap a needle that was used on a person. Always engage the safety device and put it directly into the sharps container.

The nurse is caring for a violent client who has been wearing a waist restraint for 23 hours. A family member asks if the client will continue to wear the waist restraint. What is the best response by the nurse? "The client will continue to be in restraints until violent or self-destructive behavior stops." "The client will remain in restraints until discharged." "The health care provider will see the client and assess whether the restraint prescription should be renewed." "The health care provider will see the client and prescribe tests to determine why the client is violent."

"The health care provider will see the client and assess whether the restraint prescription should be renewed."