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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. Provide a tracheostomy tray at the bedside: Incorrect. A tracheostomy tray is not necessary unless the client has a tracheostomy, which is not typically indicated for seizure precautions.

B. Place the client in supine position: Incorrect. The client should be placed on their side to prevent aspiration and promote airway patency during and after a seizure.

C. Insert an IV saline lock: A saline lock is essential in case the client needs emergency medication or fluids, especially during or after a seizure. It allows for quick IV access without continuous infusion.

D. Place a plastic tongue depressor at the client's bedside: Incorrect. A tongue depressor should never be inserted into the mouth during a seizure as it can lead to injury. The priority is to protect the client’s airway and prevent harm.

A. Place the client's hands in warm water. B. Administer a benzodiazepine. C. Place an ice pack on the client's perineum. D. Perform a fundal massage.

Correct Answer is A

Explanation

A. Place the client's hands in warm water: This action can stimulate the client’s natural reflex to urinate. The warm water helps relax the muscles involved in urination.

B. Administer a benzodiazepine: Incorrect. Benzodiazepines are not indicated for difficulty urinating postpartum and can cause unnecessary sedation.

C. Place an ice pack on the client's perineum: Incorrect. An ice pack is typically used to reduce swelling or discomfort, but it is not a primary intervention for urinary retention.

D. Perform a fundal massage: Incorrect. Fundal massage is performed to assess uterine tone, not for urinary retention.

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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

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