A nurse is caring for a client who became physically aggressive and had to be placed in mechanical restraints. Which of the following actions should the nurse take while the client is in restraints?
Hold a critical incident debriefing about the client.
Observe the client’s range of movement.
Maintain sensory stimulation for the client.
Identify stressors that caused the client’s aggression.
The Correct Answer is B
Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.
Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.
Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.
Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Wearing gloves prevents nicotine absorption through the nurse’s skin during patch application, ensuring safety and preventing side effects like dizziness. This adheres to standard precautions, critical for occupational health, maintaining hygiene, and ensuring effective nicotine therapy for clients in smoking cessation programs.
Choice B reason: Removing the previous patch is correct but placing it in tissue is inadequate; it should be folded and disposed in a sharps container. Assuming tissue disposal is sufficient risks improper handling, potentially exposing others to nicotine, critical to avoid in safe patch management.
Choice C reason: Applying the patch within 1 hour of pouch removal is unnecessary; patches remain stable longer. Wearing gloves is priority. Assuming time restriction risks rushed application, potentially compromising technique, critical to prevent in ensuring safe and effective nicotine patch therapy for smoking cessation.
Choice D reason: Shaving hairy areas risks skin irritation; trimming is preferred before patch application. Wearing gloves is essential. Assuming shaving is correct risks skin damage, reducing patch adhesion, critical to avoid in ensuring proper application and effective nicotine delivery in smoking cessation therapy.
Correct Answer is A
Explanation
Choice A reason: Confirming the client’s perception of the crisis is the first step, establishing trust and understanding their emotional state, critical for effective intervention. This guides tailored support, essential for addressing depression in a situational crisis, ensuring therapeutic communication, and promoting coping in mental health care settings.
Choice B reason: Teaching relaxation techniques is useful but secondary to understanding the client’s crisis perception, which informs interventions. Assuming techniques are first risks misaligned support, potentially escalating distress, critical to avoid in ensuring effective crisis management for clients with depression experiencing situational stressors.
Choice C reason: Identifying strengths supports coping but follows confirming the client’s crisis perception, which sets the therapeutic foundation. Prioritizing strengths risks overlooking the client’s immediate emotional needs, potentially delaying effective intervention, critical to prevent in managing depression during a situational crisis in mental health care.
Choice D reason: Notifying a support person is secondary to understanding the client’s crisis perception, which guides initial intervention. Assuming notification is first risks bypassing the client’s perspective, potentially reducing trust, critical to avoid in ensuring client-centered care for depression in situational crisis management.
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