A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

The client states that he will harm himself unless the restraints are removed.

The client demonstrates that he is oriented to person, place, and time.

The client is able to follow commands.

The client refuses to take his medication unless he is released.

Answer and Explanation

The Correct Answer is B

A. The client states that he will harm himself unless the restraints are removed.
This statement indicates a clear risk, but merely stating a desire for restraint removal is not sufficient reason to remove restraints. It's essential to assess the patient comprehensively and make the decision based on their current state and safety concerns.

B. The client demonstrates that he is oriented to person, place, and time.
When a restrained patient shows orientation to person (knows who they are and who others are), place (knows where they are), and time (knows the current date and time), it suggests they are aware of their surroundings and can make rational decisions. This orientation indicates a level of awareness that might justify removing the restraints.

C. The client is able to follow commands.
While following commands is an important aspect, it alone might not be enough to guarantee the patient's overall awareness of their situation and safety. A comprehensive assessment, including orientation and ability to follow commands, is necessary.

D. The client refuses to take his medication unless he is released.
Medication refusal alone may not be a sufficient reason to remove restraints, especially if the patient is not demonstrating an understanding of their situation or if releasing the restraints could pose a risk to the patient or others.

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Correct Answer is C

Explanation

A. Encourage the client to join group activities:
Encouraging a client experiencing a manic episode to join group activities is not the best option. Manic episodes are characterized by heightened energy, impulsive behavior, and decreased attention span. Group activities may overstimulate the client, making it difficult for them to focus or participate appropriately. It's essential to minimize stimulation and provide a calm environment to help manage the symptoms of mania.

B. Administer methylphenidate to the client:
Methylphenidate is a stimulant commonly used to treat attention deficit hyperactivity disorder (ADHD). Administering a stimulant like methylphenidate to a person in a manic state can exacerbate their symptoms. It would increase their already elevated energy levels, restlessness, and impulsivity, making the manic episode more intense and challenging to manage. Using stimulant medications in this context is contraindicated.

C. Dim the lights in the client's room:
Dimming the lights in the client's room is the appropriate choice. Bright lights can increase agitation and restlessness in individuals experiencing a manic episode. Dimming the lights creates a calming environment, reducing excessive stimulation and promoting relaxation. A calm atmosphere is crucial for someone going through a manic episode to help them manage their symptoms effectively.

D. Provide detailed explanations to the client:
During a manic episode, individuals often have racing thoughts and may have difficulty concentrating. Providing detailed explanations can overwhelm the client, as they might have trouble processing complex information in this state. Instead, simple and clear communication is more effective. It's important to provide straightforward instructions and information to prevent further agitation and confusion.

A. Naltrexone B. Disulfiram C. Lorazepam D. Acamprosate

Correct Answer is C

Explanation

A. Naltrexone:
Naltrexone is an opioid receptor antagonist. It blocks the effects of opioids and alcohol in the brain. It's often used as part of a long-term treatment plan to prevent relapse in individuals who have already stopped drinking and are trying to maintain sobriety. Naltrexone does not directly manage acute alcohol withdrawal symptoms. Instead, it helps individuals reduce or quit drinking over the long term by reducing the pleasure associated with alcohol consumption.

B. Disulfiram:
Disulfiram is an aversion therapy medication used as a deterrent to drinking. When someone taking disulfiram consumes alcohol, it causes unpleasant physical reactions, such as nausea, flushing, and palpitations. This discourages individuals from drinking while they are on the medication. Disulfiram is not used to manage acute withdrawal symptoms but rather serves as a deterrent to drinking for individuals who are trying to maintain sobriety.

C. Lorazepam:
Lorazepam is a benzodiazepine medication that acts as a central nervous system depressant. It is commonly used to manage acute alcohol withdrawal symptoms. Benzodiazepines like lorazepam help to reduce anxiety, agitation, and the risk of seizures associated with alcohol withdrawal. They are typically used in a controlled manner to provide relief during the acute phase of withdrawal.

D. Acamprosate:
Acamprosate is used in the maintenance phase of alcohol use disorder treatment. It helps individuals maintain abstinence by stabilizing the chemical imbalances in the brain that occur after prolonged alcohol use. Acamprosate is not used for acute withdrawal management but is instead prescribed to support individuals who have already stopped drinking and are trying to avoid relapse over the long term.

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A nurse is caring for a client who has physical restraints applied. The nurse determines that the restraints should be removed when which of the following occurs?

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