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A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?

Plan to monitor the client every 30 min while restrained.

Request a provider to evaluate the client in person every 36 hr.

Ensure that the prescription for restraints be renewed every 6 hr.

Document the client's behavior every 15 min.

Answer and Explanation

The Correct Answer is D

A. Monitoring every 30 minutes is insufficient; it should be more frequent.

B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.

C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.

D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.

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Correct Answer is C

Explanation

A: Disconnecting the suction to the OG tube while holding the baby is not advisable, especially if the baby is on suction due to abdominal concerns such as NEC. The OG tube is used to decompress the stomach, and disconnecting it without proper instructions can worsen the condition. Therefore, this statement indicates a lack of understanding.

B: While genetic factors may influence some neonatal conditions, NEC is not a genetic disorder. The statement about passing a gene to the baby and potentially to the next child is not accurate in this context.

C: Necrotizing enterocolitis (NEC) is a severe gastrointestinal emergency commonly seen in preterm neonates, and it can lead to bowel perforation. In cases of extensive bowel damage or perforation, surgical intervention may be required, including the possibility of an ostomy. This is a correct statement that reflects the understanding of the potential treatment plan for the neonate.

D: NEC typically involves the inability to tolerate feedings, and in such cases, feeding is often withheld temporarily. The baby would not need high-calorie formula in this situation; instead, the focus would be on managing NEC, potentially with IV nutrition or parenteral nutrition (TPN), and addressing the need for surgical intervention.

A. Lung sounds clear to auscultation B. Frequent episodes of apnea C. responds to tactile stimuli D. Temperature 36.3° C (97.3° F) E. Heart rate 158/min F. Respiratory rate 70/min G. Substernal retractions and nasal flaring noted H. Abdominal circumference increased by 1 cm (0.4 in) since the prior assessment

Correct Answer is ["B","C","D","F","G","H"]

Explanation

Frequent episodes of apnea, responds to tactile stimuli: Apnea in a neonate, especially one born preterm (at 34 weeks gestation), is not uncommon but should be carefully monitored. However, frequent apnea episodes may indicate an underlying respiratory issue, such as respiratory distress syndrome (RDS) or an infection. Apnea that requires tactile stimuli to resolve should be followed up with further assessment and possibly intervention.

Substernal retractions and nasal flaring: These are signs of respiratory distress. Substernal retractions and nasal flaring indicate the neonate is working harder to breathe, which may point to respiratory distress syndrome (RDS) or other respiratory compromise. Close monitoring and follow-up are necessary to assess the neonate's respiratory status and oxygenation.

Respiratory rate of 70/min: This is on the higher end for a neonate and may indicate respiratory distress or compensation for oxygenation issues. Close monitoring is required.

Temperature of 36.3 °C (97.3 °F): While this temperature is within the normal range for a neonate, it is on the lower end of the spectrum. Neonates, especially preterm ones, are at risk for hypothermia. The neonate is on a radiant warmer, which suggests that there may still be concerns regarding temperature regulation. This needs to be monitored closely to ensure proper thermal regulation.

Increased abdominal circumference by 1 cm (0.4 in): An increase in abdominal circumference can be a sign of feeding intolerance, such as necrotizing enterocolitis (NEC), or other gastrointestinal issues. It is important to continue monitoring for other signs of NEC or abdominal distension, which can indicate the need for intervention.

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A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a neonate in the neonatal intensive care unit. Exhibits Which of the following statements made by the caregiver indicates an understanding of the plan of care?

Correct Answer is C

Explanation

Correct Answer is ["B","C","D","F","G","H"]

Explanation

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