A nurse is assisting in the care of a client who is in restraints following an episode of violence. Which of the following information should the nurse document in the client's medical record? (Select all that apply.)
Providing opportunities for nutrition and toileting
Observing range of motion of client's extremities
Observation of the client once per hour
Attempts at less restrictive interventions
Names of staff members caring for the client
Correct Answer : A,B,D,E
A. It is essential to document the times when the client was offered opportunities for nutrition and toileting while in restraints. This includes offering food and fluids at regular intervals and assisting the client with toileting needs as required. Documentation ensures that these basic needs are met despite the restraint status.
B. Documenting observations of the client's range of motion helps monitor for any signs of discomfort, circulation issues, or injury related to being in restraints. This documentation is crucial for ensuring the client's safety and well-being during restraint use.
C. observation of the client should be conducted more frequently than once per hour, especially after an episode of violence, to closely monitor the client's condition and response to the restraints.
D. Documenting attempts at less restrictive interventions shows that the healthcare team is actively working to minimize the use of restraints whenever possible. This might include attempts to de-escalate the client, use of medications, or other interventions aimed at reducing agitation or violence without resorting to physical restraints.
E. It is important to document the names of staff members who are directly involved in the care of a restrained client. This ensures accountability and provides a clear record of who has been caring for the client during their restraint period.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cardiac arrhythmias can be a concern during ECT due to the potential cardiovascular effects of the electrical stimulation. It's crucial to ensure that the client's cardiac status is stable before proceeding with ECT. Certain arrhythmias may require management or stabilization before the procedure can be safely performed.
B. Crohn's disease, an inflammatory bowel disease, may not directly impact the safety of ECT. However, it's important to review if the client is currently experiencing an active flare-up or complications such as dehydration or electrolyte imbalances, which could affect their overall health and readiness for the procedure.
C. Asthma itself is typically not a contraindication for ECT. However, if the client has poorly controlled asthma or is experiencing an exacerbation, it could pose a risk during the procedure, especially if sedation or anesthesia is used. The nurse should ensure asthma is well-managed before proceeding with ECT.
D. Renal colic refers to pain caused by kidney stones. This condition is not typically a direct contraindication for ECT. However, pain and discomfort from renal colic could affect the client's tolerance of the procedure, especially if sedation or anesthesia is required.
Correct Answer is B
Explanation
A. Risperidone is an antipsychotic medication used to treat conditions like schizophrenia and bipolar disorder. It is not indicated for smoking cessation and does not have any direct effect on nicotine withdrawal or cravings. Therefore, it would not be included in discussions about smoking cessation medications.
B. Bupropion is a medication that is FDA-approved for smoking cessation. It works by reducing nicotine cravings and withdrawal symptoms. It is available in sustained-release formulations specifically marketed for smoking cessation under the brand name Zyban. Bupropion can be effective in helping individuals quit smoking and is often recommended as a first-line treatment.
C. Aripiprazole is an antipsychotic medication used primarily to treat conditions such as schizophrenia, bipolar disorder, and major depressive disorder. It does not have any specific indication or role in smoking cessation. Therefore, it would not typically be included in discussions about medications for quitting smoking.
D. Quetiapine is another antipsychotic medication used to treat conditions like schizophrenia, bipolar disorder, and major depressive disorder. Similar to aripiprazole and risperidone, it does not have any direct role in smoking cessation. It is not indicated for reducing nicotine cravings or aiding in smoking cessation efforts.
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