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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Upper extremity hypotension is not a common finding in coarctation of the aorta. Coarctation of the aorta typically results in narrowing of the aorta, leading to decreased blood flow to the lower part of the body. This can cause weak or absent femoral pulses and lower extremity hypotension, not upper extremity hypotension.
Choice B rationale:
Frequent nosebleeds are not directly associated with coarctation of the aorta. The symptoms of coarctation of the aorta are primarily related to decreased blood flow to the lower extremities, leading to symptoms such as weak femoral pulses, lower extremity hypotension, and leg cramping or pain.
Choice D rationale:
Increased intracranial pressure is not a typical finding in coarctation of the aorta. Coarctation of the aorta affects blood flow to the lower part of the body and does not directly impact intracranial pressure.
Correct Answer is C
Explanation
The correct answer is c. Use an albuterol inhaler.
Choice A reason: Eating a meal before postural drainage is not recommended because it can cause discomfort, nausea, or vomiting due to the positions required for the procedure.
Choice B reason: Taking pancrelipase is important for aiding digestion in cystic fibrosis patients, but it is not specifically related to the preparation for postural drainage.
Choice C reason: Bronchodilators like albuterol are used before airway clearance techniques to open the airways, making it easier to clear mucus during postural drainage.
Choice D reason: While maintaining oral hygiene is important for overall health, it is not a preparation step for postural drainage.
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