A nurse in an acute mental-health facility is caring for an adolescent who is exhibiting destructive behavior. Which of the following actions should the nurse take after applying physical restraints to the client?
Monitor the client's range of motion every 60 min.
Offer the client a nutritious snack every 4 hr.
Plan to remove the restraints as soon as the client is calm
Ensure that the provider has signed a prescription for restraints within 48 hr.
The Correct Answer is C
The correct answer is C. Plan to remove the restraints as soon as the client is calm. Physical restraints should be used as a last resort and for the shortest duration possible to ensure
client safety. The nurse should assess the client frequently and remove the restraints when they are no longer needed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is C. Identifying the client's perception of the changes in her physical appearance is essential for developing a plan of care that addresses her psychosocial needs and promotes her self-esteem and body image. The client may experience grief, anger, depression, anxiety, or guilt after losing her breasts, which can affect her quality of life and recovery. The nurse should explore how the client feels about herself and her sexuality, and provide emotional support and empathy. The other actions are also important, but they are not as a priority as understanding how the client views herself.
Correct Answer is D
Explanation
Choice A reason:
This is a mild analgesic and antipyretic. It may be inadequate for moderate pain such as that from cholelithiasis (gallstones).
Choice B reason:
Omeprazole Omeprazole should not administer because it is a proton pump inhibitor (PPI) used to reduce stomach acid production and treat conditions such as gastroesophageal reflux disease (GERD) and peptic ulcers. It is not indicated for the treatment of pain and discomfort associated with cholelithiasis.
Choice C reason
Should not be administered
Metoclopramide Metoclopramide should not be administered because it is a medication used to treat gastrointestinal issues such as nausea, vomiting, and gastroparesis. It is not indicated for the treatment of pain associated with cholelithiasis.
Choice D reason:
Ketorolac: This is a nonsteroidal anti-inflammatory drug (NSAID) appropriate for moderate to severe pain, including biliary colic due to cholelithiasis. It is often used PRN for acute pain relief.
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