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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. A BMI of 20 falls within the healthy weight range for adults.

B. Malnutrition is characterized by a BMI below the healthy weight range and is typically associated with BMI values less than 18.5.

C. Overweight is characterized by a BMI between 25 and 29.9.

D. Obesity is characterized by a BMI of 30 or higher.

A. Use the injection port farthest from the IV catheter insertion site. B. Occlude the IV tubing above the injection port. C. Check for blood return after medication administration. D. Flush the IV tubing with a heparinized solution.

Correct Answer is B

Explanation

A. Using the injection port farthest from the IV catheter insertion site is not necessary for administering an IV bolus of medication and may not be practical depending on the setup of the IV tubing.

B. Occluding the IV tubing above the injection port prevents the bolus medication from flowing into the continuous IV infusion, ensuring that the medication is delivered directly to the patient.

C. Checking for blood return after medication administration is not relevant in this context, as albumin 5% is administered intravenously and does not require blood return.

D. Flushing the IV tubing with a heparinized solution is not necessary for administering an IV bolus of medication and may not be appropriate for all medications.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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