A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?
Document the client's behavior hourly on a flow sheet.
Request a PRN client prescription for restraints from the provider.
Observe the client's behavior once every 15 min.
Remove the restraint when the client calmly follows commands.
The Correct Answer is C
A. Document the client's behavior hourly on a flow sheet: While documentation is important, it is more frequent than hourly. Clients in restraints should be observed and documented on more frequently, usually every 15 minutes to ensure safety and assess the client's condition.
B. Request a PRN client prescription for restraints from the provider: Restraints require a specific order from the provider, not a PRN (as needed) prescription. The order must be obtained initially and renewed per the facility's policy, typically every 24 hours.
C. Observe the client's behavior once every 15 minutes: Clients in restraints must be closely monitored for safety and well-being. The nurse should assess the client’s condition, including physical and emotional status, every 15 minutes.
D. Remove the restraint when the client calmly follows commands: Restraints should only be removed under appropriate conditions as assessed by the nurse, and with a provider’s order when necessary. The client's behavior alone does not determine the removal of restraints.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Dwelling on these struggles will not help you move past your loss.": This response dismisses the client’s feelings and may minimize their grief. Acknowledging their emotions is important for therapeutic communication, and telling the client to stop dwelling may feel invalidating.
B. "Everyone struggles with loss, but you'll be okay in time.": While this response is intended to offer comfort, it may sound dismissive and could undermine the client’s grief experience. Each person processes loss differently, and it's important to acknowledge their feelings.
C. "Attending a support group may help both you and your partner.": This response is supportive and practical. It acknowledges that grief affects both individuals in a relationship and suggests a helpful resource. Support groups provide validation and connection with others going through similar experiences.
D. "Spend more time focusing on your relationship with your partner.": This response oversimplifies the situation and does not acknowledge the depth of the client’s grief. It may feel directive and might not address the underlying emotional need.
Correct Answer is B
Explanation
A. The client is experiencing anisognosia: Anisognosia, a lack of awareness of one's own illness, is common in various psychiatric disorders, particularly in psychotic disorders like schizophrenia. While it is concerning, it does not typically require immediate reporting.
B. The client is experiencing command hallucinations: Command hallucinations, where the client hears voices telling them to take harmful actions, pose a direct safety risk. These should be immediately reported to the provider for further evaluation and intervention.
C. The client is exhibiting concrete thinking: Concrete thinking is common in individuals with certain psychiatric conditions, such as schizophrenia or intellectual disabilities. While it limits abstract thought, it is not an immediate cause for alarm.
D. The client is exhibiting a blunted affect: A blunted affect, or reduced emotional expression, is a common symptom in various mental health disorders. It is important for diagnosis and treatment planning but is not an immediate emergency or urgent situation.
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