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.
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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Related Questions
Correct Answer is C
Explanation
A. Battery involves actual physical contact without consent.
B. Negligence refers to failing to provide appropriate care, leading to harm.
C. Assault occurs when a person is threatened with harm or offensive contact, creating fear, even if no physical contact occurs. Telling the client that a catheter will be inserted without consent can be perceived as a threat.
D. Libel is a false written statement that damages someone’s reputation.
Correct Answer is C
Explanation
A. Milkshake made with whole milk is high in saturated fats and sugar, making it less healthy.
B. Cheesecake is a high-calorie, high-fat dessert and not a healthy snack option.
C. Air-popped popcorn is a whole grain, low-calorie, and fiber-rich snack, making it a healthy choice.
D. Baked potato chips are a better option than fried chips but still contain added salt and fat.
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