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?
Request a provider to evaluate the client in person every 36 hr.
Document the client's behavior every 15 min.
Ensure that the prescription for restraints be renewed every 6 hr.
Plan to monitor the client every 30 min while restrained.
The Correct Answer is B
Choice A rationale:
Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.
Choice B rationale:
Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.
Choice C rationale:
Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.
Choice D rationale:
Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
A heart rate of 140/min is not a specific indicator of desmopressin effectiveness in a child with diabetes insipidus. The effectiveness of desmopressin is primarily evaluated based on the reduction in excessive urination and thirst associated with the condition. Monitoring heart rate is essential in certain situations but is not a direct measure of desmopressin efficacy in managing diabetes insipidus.
Choice B rationale:
Cessation of nocturnal enuresis (bedwetting) is a significant indication that desmopressin, an antidiuretic hormone, is effective. One of the main symptoms of diabetes insipidus is excessive urination, including during the night, leading to bedwetting. When desmopressin effectively reduces urine production, patients often experience improvement in these symptoms, including the cessation of nocturnal enuresis.
Choice C rationale:
Capillary refill of 3 seconds is a measurement used to assess peripheral perfusion and circulatory status. While it is essential to monitor capillary refill in pediatric patients, especially in cases of dehydration or circulatory compromise, it is not a specific indicator of desmopressin effectiveness in managing diabetes insipidus. Capillary refill time is more relevant in the assessment of cardiovascular function and fluid status.
Choice D rationale:
The absence of hypoglycemic episodes is not a direct indicator of desmopressin effectiveness. Diabetes insipidus is unrelated to blood glucose levels, as it involves the dysregulation of water balance due to insufficient antidiuretic hormone. While it is essential to monitor blood glucose levels in patients with diabetes mellitus, it is not relevant to assessing the effectiveness of desmopressin in treating diabetes insipidus.
Correct Answer is B
Explanation
The correct answer is Choice B: "When using implanted contraceptive methods, condoms should also be used to protect against STDs."
Choice B rationale: While implanted contraceptive methods are highly effective in preventing unintended pregnancies, they do not provide protection against sexually transmitted diseases (STDs). Therefore, using condoms in conjunction with implanted contraceptives can enhance overall sexual health by reducing the risk of contracting or transmitting STDs. This statement highlights the nurse's understanding of the importance of comprehensive sexual health practices and the limitations of various contraceptive methods.
Choice A rationale: The use of petroleum-based lubricants with condoms can actually compromise their effectiveness. Petroleum-based lubricants can degrade latex condoms, increasing the likelihood of condom breakage or slippage, which in turn raises the risk of both pregnancy and STD transmission.
Choice C rationale: Condoms are indeed effective in preventing pregnancy, but their effectiveness can be enhanced by using them in conjunction with vaginal spermicides. Spermicides containing nonoxynol-9 can provide additional protection by inactivating or killing sperm, thus reducing the risk of pregnancy.
Choice D rationale: Ensuring a proper fit is crucial for a condom's effectiveness, but the statement only emphasizes the condom fitting snugly over the tip of the penis. For optimal protection, a condom should be unrolled to cover the entire erect penis, leaving a small empty space at the tip for semen collection. A condom that is not unrolled completely may be more likely to slip off or break during intercourse.
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