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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Avoid over-the-counter magnesium when taking this medication: There is no specific contraindication between doxepin and magnesium supplements. However, clients should consult their healthcare provider before using any over-the-counter products.
B. Eat a snack before going to bed: While this is not incorrect for some medications, it is not a primary teaching point for doxepin. The medication's primary side effect concerns are sedation and orthostatic hypotension, not hunger-related issues.
C. Sit on the side of the bed for a few minutes before standing: Doxepin, a tricyclic antidepressant, can cause orthostatic hypotension, leading to dizziness when standing. Sitting on the side of the bed before standing helps reduce this risk by allowing the body to adjust to the change in position.
D. Decrease the prescribed dose by half when mood improves: Clients should never adjust their prescribed medication dose without consulting their provider. Abruptly stopping or reducing the dose can cause withdrawal symptoms or a relapse of depressive symptoms.
Correct Answer is A
Explanation
A. "The night shift nurse is terrible.": This is an example of displacement, where the client redirects feelings of anger or frustration from a more significant issue, such as personal conflict or stress, onto an unrelated person like the night shift nurse.
B. "If I do what I am supposed to do, it will go away.": This statement reflects an attempt at problem-solving or avoidance rather than displacement. The client is trying to manage the situation directly by taking action, rather than transferring emotions.
C. "I am so angry with my spouse.": This is a direct acknowledgment of the source of the distress (the spouse) and does not involve displacement. The client is openly expressing anger rather than redirecting it onto someone or something unrelated.
D. "I don't know why I am here in the first place.": This reflects denial, where the client avoids recognizing the true reasons for being in treatment. The client is avoiding confronting their feelings or the situation but isn’t displaying displacement.
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