A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?
Remove the restraints from the client.
Offer the client PRN pain medication.
Continue to monitor the client every 15 min.
Encourage the client to attend a group therapy session.
The Correct Answer is A
Rationale:
A. Remove the restraints from the client: Restraints should be discontinued as soon as the client no longer poses a danger to themselves or others. Prompt removal prevents unnecessary restriction and respects the client’s rights and dignity.
B. Offer the client PRN pain medication: While assessing for discomfort is important, pain medication is not the immediate priority once the client is calm and cooperative, unless the client requests it or shows signs of pain.
C. Continue to monitor the client every 15 min: Monitoring should continue after restraint removal according to facility policy, but the first action is to remove the restraints to avoid unnecessary confinement.
D. Encourage the client to attend a group therapy session: While therapeutic activities are important, this is not the immediate action following restraint use. Ensuring the client’s safety and removing restraints takes priority.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "I will plan to continue taking this medication for at least 5 years.": Disulfiram therapy is not prescribed for a fixed duration such as 5 years. The length of treatment depends on the client’s motivation and response, typically continuing until long-term abstinence is maintained.
B. "My provider wants me to take this medication for 2 weeks before I try to quit drinking.": Disulfiram must be started only after the client has abstained from alcohol for at least 12 hours, not before quitting. Taking it while alcohol is still in the system can trigger severe reactions such as flushing, nausea, vomiting, and hypotension.
C. "I should avoid over-the-counter medications that contain alcohol.": Even small amounts of alcohol—such as in cough syrups, mouthwash, or sauces—can cause a dangerous disulfiram-alcohol reaction. Clients must avoid all alcohol-containing products.
D. "I will need to get a monthly injection of this medication.": Disulfiram is taken orally, usually once daily, and does not come in injectable form. The injectable medication used for alcohol dependence is naltrexone (Vivitrol).
Correct Answer is ["C","D","E"]
Explanation
Rationale:
A. Acetone breath odor: A fruity or acetone breath odor occurs when the body produces ketones due to fat breakdown in hyperglycemia or diabetic ketoacidosis (DKA). This finding is not associated with hypoglycemia but rather prolonged high blood glucose levels.
B. Polydipsia: Excessive thirst (polydipsia) is a sign of hyperglycemia because the kidneys attempt to excrete excess glucose, leading to dehydration. It does not occur during hypoglycemia, when blood sugar levels are abnormally low.
C. Inability to concentrate: Low blood glucose deprives the brain of its primary energy source, leading to confusion, irritability, and difficulty concentrating. These neuroglycopenic symptoms are hallmark signs of hypoglycemia and can progress to altered consciousness if untreated.
D. Diaphoresis: Sweating is a classic adrenergic response to hypoglycemia as the body releases epinephrine to raise blood glucose levels. It serves as an early warning sign, prompting immediate carbohydrate intake to prevent further decline in blood sugar.
E. Tremors: Tremors occur due to increased sympathetic nervous system activity during hypoglycemia. The body responds to falling glucose by releasing catecholamines, which stimulate muscle activity and cause shaking or trembling sensations.
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