A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit?

The client eats all of the food provided for each of her meals.

The client requests to use the bathroom.

The client follows directions.

The client's vital signs are within the expected reference range.

Answer and Explanation

The Correct Answer is B

A. Eating all of the food provided for each of her meals may indicate that the client is physically stable, but it doesn't directly reflect the client's readiness to reintegrate socially or behaviorally into the unit.

B. The client requests to use the bathroom is the most appropriate indicator of readiness to reintegrate. This demonstrates that the client is regaining some level of control over their environment and is able to communicate basic needs. It's a sign of behavioral and emotional readiness to resume participation in regular activities.

C. Following directions is important, but it alone does not necessarily indicate emotional or behavioral readiness to reintegrate. The client may still need further assessment of their emotional state and impulse control before being reintegrated.

D. While vital signs being within the expected reference range is important for physical stability, it does not provide enough information regarding the client's emotional and behavioral readiness for reintegration.

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Correct Answer is C

Explanation

A. Instruct the client on relaxation techniques for use when anxiety increases. While relaxation techniques can help manage anxiety, it is more important initially to understand the client's triggers for compulsive behaviors before teaching coping strategies. This helps in addressing the root cause of the anxiety.

B. Discuss alternative coping strategies with the client. Although this is a valuable part of long-term management, addressing the triggers for the ritualistic behaviors takes priority to develop a focused and personalized plan for coping.

C. Identify precipitating factors for ritualistic behaviors. This is the most important first step. Identifying the triggers for the obsessive-compulsive behaviors allows the nurse to understand the specific anxiety or distress causing the compulsive actions. Once these factors are known, it becomes easier to develop an appropriate care plan to reduce or manage the compulsive rituals.

D. Provide a structured activity schedule for the client. While structure can be helpful for clients with OCD, it is more important to understand the underlying anxiety and compulsive behaviors first. Providing a schedule without understanding the triggers might not be as effective.

A. "This medication will be administered by intramuscular injection every 2 weeks." B. "I should expect to develop ringing in my ears while taking this medication." C. "I will rise slowly from a lying position to prevent fainting while taking this medication." D. "This medication will help prevent seizures."

Correct Answer is C

Explanation

A. "This medication will be administered by intramuscular injection every 2 weeks." Clozapine is typically taken orally in tablet form, not as an intramuscular injection.

B. "I should expect to develop ringing in my ears while taking this medication." Ringing in the ears (tinnitus) is not a common or expected side effect of clozapine. The nurse should inform the client about the possible side effects of clozapine, but tinnitus is not typically one of them.

C. "I will rise slowly from a lying position to prevent fainting while taking this medication." Clozapine can cause orthostatic hypotension, a drop in blood pressure when standing up, which can lead to dizziness or fainting. The client should be educated to rise slowly from a lying or sitting position to reduce this risk.

D. "This medication will help prevent seizures." Clozapine actually increases the risk of seizures, particularly at higher doses. The client should be aware of this risk, and the nurse should monitor for signs of seizures while the client is on this medication.

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A nurse in an inpatient mental health unit is planning care for a client who is in restraints. Which of the following findings should indicate to the nurse that the client is ready to reintegrate into the unit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a newly admitted client who has obsessive-compulsive disorder (OCD). Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

A nurse is providing teaching for a client who has a new prescription for clozapine. Which of the following statements indicates the client understands the teaching?

Correct Answer is C

Explanation

A nurse is discussing the use of mechanical restraints with a newly licensed nurse. Which of the following situations should the nurse include as an indication for placing a client in mechanical restraints?

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