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.

Answer and Explanation

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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Correct Answer is ["A","B","C","D"]

Explanation

Rationale for correct choices:

Ask a trusted person to watch for manifestations of illness: Involving a trusted person in monitoring symptoms can help identify early signs of relapse. Sometimes, clients may not notice subtle changes in their mental state, so a reliable individual can alert the healthcare provider, allowing for early intervention.
Notify your provider within 48 hr of manifestations of a relapse: Early detection and intervention are key to preventing a full relapse. By notifying the provider within 48 hours, the healthcare team can adjust medications or other interventions promptly, reducing the severity of symptoms.
Go for a walk to decrease anxiety during times of increased stress: Physical activity, like walking, is beneficial for managing anxiety, which is a common trigger in individuals with schizophrenia. Regular exercise can also promote mental well-being, making it a helpful strategy for coping with stress.
Report any adverse effects of the medication to the provider immediately: Antipsychotic medications like haloperidol can cause significant side effects, and reporting these early allows the provider to manage or adjust the treatment plan, preventing complications such as extrapyramidal symptoms or neuroleptic malignant syndrome.

Rationale for incorrect choices:

Limit alcohol consumption to no more than two drinks per week: Alcohol should be avoided entirely, as it can interfere with the effectiveness of antipsychotic medications and worsen psychiatric symptoms.
Take a dose of the medication as soon as delusions or hallucinations begin: Medications for schizophrenia, like haloperidol, should be taken as prescribed, and adjustments to dosage or frequency should only be made under the guidance of a healthcare provider.

A. Assign the client to a different caregiver each shift. B. Teach the client assertive techniques. C. Refute the client's perception of visual hallucinations D. Reinforce the client's orientation with a calendar.

Correct Answer is D

Explanation

A. Assign the client to a different caregiver each shift: This is not ideal for a client with acute delirium. Consistency in caregivers is important to reduce confusion and help the client feel more secure in a familiar environment.

B. Teach the client assertive techniques: Assertiveness training is more appropriate for clients with anxiety or communication difficulties, not for those with acute delirium. In delirium, the priority is managing cognitive function and safety.

C. Refute the client's perception of visual hallucinations: Refuting hallucinations can cause frustration and worsen the client's confusion. It’s better to acknowledge the hallucinations calmly without validating them, offering reassurance instead of confrontation.

D. Reinforce the client's orientation with a calendar: This is an appropriate intervention. Using a calendar, clock, and other orientation tools helps reinforce reality and can reduce confusion in clients with delirium, aiding in their cognitive stabilization.

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A nurse is caring for a client who has been placed in restraints. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia and is preparing for discharge. Exhibits The nurse is providing discharge teaching to the client. Which of the following information should the nurse include when educating the client about relapse prevention? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is D

Explanation

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