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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
Explanation
|
Potential prescription |
Anticipated |
Contraindicated |
|
Bupropion 100 mg PO three times daily |
✓ |
|
|
Levomilnacipran 20 mg PO daily |
✓ |
|
|
Citalopram 20 mg PO daily |
✓ |
|
|
Fluoxetine 20 mg PO daily |
✓ |
Rationale
- Bupropion 100 mg PO three times daily: Contraindicated
- Bupropion is generally contraindicated for clients with a history of bulimia nervosa due to the increased risk of seizures.
- Levomilnacipran 20 mg PO daily: Anticipated
- Levomilnacipran is an SNRI that can be used to treat major depressive disorder and is generally safe for clients with bulimia nervosa.
- Citalopram 20 mg PO daily: Anticipated
- Citalopram is an SSRI commonly used to treat major depressive disorder and can be effective for clients with bulimia nervosa.
- Fluoxetine 20 mg PO daily: Anticipated
- Fluoxetine is an SSRI that is effective in treating both major depressive disorder and bulimia nervosa.
Correct Answer is C
Explanation
A. Wearing well-fitted shoes at home helps prevent slips and falls.
B. Placing throw rugs over electrical cords increases the risk of tripping.
C. Area rugs with rubber backs prevent slipping, reducing the risk of falls in a postoperative client.
D. Marking doorways with tape is not necessary for a client after knee replacement and may be more applicable for clients with visual impairments.
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