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 []
Explanation
Potential condition: Deep vein thrombosis
Based on the provided information, the client is most likely experiencing Deep Vein Thrombosis (DVT). This is suggested by the client's history of smoking, lack of exercise, obesity, recent surgery, and the fact that they are not wearing sequential compression devices due to discomfort.
Actions to Take
- Request a prescription for a lower-extremity Doppler flow study: This will help confirm the presence of a blood clot in the deep veins.
- Assess for Homan's sign: This is a clinical test used to check for DVT, although it's not always reliable.
Parameters to Monitor
- Signs of bleeding after anticoagulation initiation: This is crucial because anticoagulants are often used to treat DVT, and monitoring for bleeding is essential.
- PT/INR and platelet count: These parameters help assess the effectiveness and safety of anticoagulation therapy.
Correct Answer is B
Explanation
A. While noting changes in the medical record is important, it doesn’t specifically address communication between staff members.
B. Having interdisciplinary team meetings on a regular basis ensures that all healthcare providers involved in the client’s care are informed of the current treatment plan, goals, and changes. This promotes communication and collaboration across disciplines, which is especially important in the care of clients with conditions like expressive aphasia.
C. Recording progress in the nurses’ notes is important, but it alone does not foster active communication between different team members.
D. Posting swallowing precautions is important for the safety of the client but doesn’t address the need for better communication among the team.
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