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 D
Explanation
A. Aspiration: Succinylcholine is used during electroconvulsive therapy (ECT) to induce muscle relaxation, but it does not specifically prevent aspiration. Aspiration risk is generally minimized by using an endotracheal tube and appropriate airway management during the procedure, not just succinylcholine.
B. Decreased heart rate: Succinylcholine is not used to manage heart rate. While ECT can cause heart rate fluctuations, other medications, like atropine, are typically used if bradycardia is a concern.
C. Elevated blood pressure: Succinylcholine does not address blood pressure regulation. ECT can cause temporary increases in blood pressure, but succinylcholine is used to relax muscles and does not manage blood pressure.
D. Muscle distress: Succinylcholine is given during ECT to relax muscles and prevent muscle contractions or "muscle distress" during the procedure. Without muscle relaxation, muscle contractions during the procedure could cause injury or severe discomfort.
Correct Answer is A
Explanation
A. Decrease in blood pressure: A decrease in blood pressure is a positive sign that the treatment for serotonin syndrome is effective. Treatment typically includes discontinuing the causative medication and providing supportive care to normalize vital signs, including blood pressure.
B. Muscle rigidity: Muscle rigidity is a hallmark sign of serotonin syndrome and indicates that the condition is still present or not yet effectively treated. Successful treatment should reduce muscle rigidity over time.
C. Hyperreflexia: Hyperreflexia (overactive reflexes) is also a common symptom of serotonin syndrome. If the treatment is effective, hyperreflexia should resolve as serotonin levels normalize in the body.
D. Altered mental status: Altered mental status is another indicator of serotonin syndrome. Improvement in serotonin syndrome would be evidenced by a return to normal cognitive function, so persistence of altered mental status suggests that treatment has not yet been fully effective.
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