A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints?
The client follows the nurse's simple instructions.
The client apologizes for their aggressive behavior.
The client requests that the restraints be removed.
The client maintains eye contact while talking with the nurse.
The Correct Answer is A
- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Crepitus is not typically associated with right ventricular heart failure; it may indicate subcutaneous emphysema or air leakage into the tissues.
B. Right ventricular heart failure often leads to elevated pulmonary artery pressure due to increased pressure in the pulmonary circulation.
C. Hepatosplenomegaly may occur in congestive heart failure but is not specific to right ventricular heart failure.
D. Confusion may occur in severe cases of heart failure due to decreased cerebral perfusion, but it is not specific to right ventricular heart failure.
Correct Answer is C
Explanation
A. Mixing ferrous sulfate capsules with food may alter the absorption of the medication. It is generally recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce
irritation.
B. Dissolving ferrous sulfate capsules in chocolate milk or any other liquid may affect the taste and consistency of the drink. Additionally, chocolate milk may contain substances that could
interfere with iron absorption.
C. Administering iron supplements with a glass of orange juice is a common recommendation because vitamin C enhances the absorption of iron. This combination helps improve the bioavailability of the iron supplement.
D. There is no specific indication to administer ferrous sulfate capsules at bedtime. It is typically recommended to take iron supplements on an empty stomach for better absorption, unless gastrointestinal side effects occur, in which case taking it with food can help reduce irritation.
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