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.

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason: A semi-sitting position for meals is impractical in a hip spica cast, risking discomfort or aspiration; turning every 2 hours prevents pressure injuries. Assuming semi-sitting is correct risks complications, critical to avoid in ensuring safe positioning and care for children in spica casts.

Choice B reason: Maintaining dependent lower extremities increases edema risk in a hip spica cast; turning every 2 hours promotes circulation. Assuming dependent positioning is correct risks swelling, critical to prevent in ensuring proper cast care and comfort for children with hip spica casts.

Choice C reason: A bedside commode is unsuitable for a hip spica cast, which covers the pelvis; bedpans are used. Turning every 2 hours is key. Assuming a commode is appropriate risks impracticality, critical to avoid in ensuring proper toileting and care in spica cast management.

Choice D reason: Turning every 2 hours prevents pressure ulcers and promotes circulation in a child with a hip spica cast, critical for skin integrity and comfort. This ensures proper cast care, reducing complications, supporting healing, and maintaining safety in pediatric orthopedic management.

A. Provide unleavened bread. B. Provide chicken with a cream sauce. C. Avoid serving fish with fins and scales. D. Avoid serving foods containing lamb.

Correct Answer is A

Explanation

Choice A reason: Unleavened bread (matzah) is required during Passover in Orthodox Judaism, as leavened products are prohibited. Providing it respects dietary laws, critical for cultural sensitivity, ensuring nutritional needs, and supporting client comfort, aligning with patient-centered care principles during religious observances in healthcare settings.

Choice B reason: Chicken with cream sauce is prohibited during Passover, as Orthodox Jews avoid mixing meat and dairy (kosher laws). Unleavened bread is appropriate. Serving this risks dietary violation, causing distress, critical to avoid in ensuring culturally sensitive care for clients observing Passover in healthcare settings.

Choice C reason: Fish with fins and scales is kosher and permitted during Passover, not to be avoided. Unleavened bread aligns with Passover rules. Assuming fish avoidance risks unnecessary restriction, potentially affecting nutrition, critical to prevent in supporting dietary adherence for Orthodox Jewish clients during Passover.

Choice D reason: Lamb is permitted during Passover if kosher, not universally avoided. Unleavened bread is a dietary staple. Assuming lamb avoidance risks misaligned care, potentially causing nutritional or cultural issues, critical to avoid in ensuring respectful, adherent care for Orthodox Jewish clients observing Passover.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has a hip spica cast. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is planning care for a client who practices Orthodox Judaism and is observing the Passover holiday. Which of the following actions should the nurse include in the plan of care?

Correct Answer is A

Explanation

A nurse is caring for a client who is postoperative immediately following a cardiac catheterization with a right femoral approach. Which of the following actions should the nurse take?

A nurse is providing teaching to the parents of a newborn who has been circumcised. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who reports a headache and has a history of a peptic ulcer. Which of the following medications should the nurse administer?

A nurse is performing wound care for a client who has an abdominal incision. Which of the following techniques should the nurse implement?

A nurse is assessing a client who has preeclampsia and is receiving magnesium sulfate via continuous IV infusion. For which of the following therapeutic effects should the nurse monitor the client?

A nurse is caring for a client admitted for alcohol use disorder who reports using alcohol to deal with stress. Which of the following actions should the nurse take to assist the client in maintaining self-control of the behavior?

A nurse is preparing a toddler for a procedure. Which of the following actions should the nurse plan to take?

A nurse is completing an incident report after a client fall. Which of the following competencies of Quality and Safety Education for Nurses is the nurse demonstrating?