A mental health nurse is planning care for a group of clients.
Which of the following clients should the nurse identify as having a contraindication for applying restraints?
A client who has Obsessive Compulsive Disorder (OCD) and insists on mopping the floor in the day room.
A client who has a personality disorder and tries to manipulate the staff to gain privileges.
A client who has Bulimia Nervosa and refuses to come to the dining room for meals.
A client who is just recovering from a benzodiazepine overdose.
The Correct Answer is D
Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive
thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.
Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.
While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.
Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.
Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Deflecting the client's concerns to the physician dismisses the client's immediate need for emotional support and therapeutic communication.
It can hinder the development of a trusting nurse-client relationship.
The nurse is responsible for addressing the client's psychosocial needs, not solely deferring them to other healthcare professionals.
Choice B rationale:
Offering false reassurance is inappropriate and potentially harmful. It can erode trust if the client's fears are later realized.
It minimizes the client's legitimate concerns and invalidates their emotional experience.
Choice C rationale:
While lifestyle modifications are essential for managing coronary artery disease, providing unsolicited advice at this moment disregards the client's emotional distress.
It prioritizes physical health over the client's psychological well-being. It can be perceived as dismissive of the client's fears and concerns.
Choice D rationale:
Inviting the client to elaborate on their fears demonstrates active listening and encourages therapeutic communication. It validates the client's concerns and shows empathy for their emotional experience.
It provides an opportunity to assess the client's understanding of their condition and identify specific fears or misconceptions. It establishes a foundation for exploring coping mechanisms and providing appropriate support and education.
Correct Answer is ["10"]
Explanation
To calculate the amount of fluoxetine to administer, we can use the following steps:
Step 1: Identify the desired dose, which is 40 mg.
Step 2: Identify the available dose, which is 20 mg/5 mL.
Step 3: Set up the equation to solve for the unknown, which is the volume in mL. The equation is (Desired Dose ÷ Available Dose) × Volume = Volume to Administer.
Step 4: Substitute the known values into the equation: (40 mg ÷ 20 mg) × 5 mL = Volume to Administer. Step 5: Solve the equation: 2 × 5 mL = 10 mL.
So, the nurse should administer 10 mL of fluoxetine.
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