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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "This medication is given to help with extrapyramidal side effects."
Benztropine is an anticholinergic medication used to treat the extrapyramidal side effects (EPS) caused by certain psychiatric drugs, particularly antipsychotics. EPS can include symptoms such as muscle stiffness, restlessness, tremors, and other movement disorders. Benztropine helps to alleviate these symptoms, making it an essential medication for individuals experiencing these side effects from antipsychotic medications.
B. "Benztropine helps alleviate your hallucinations."
This statement is incorrect. Benztropine is not primarily used to treat hallucinations; it is used for movement-related side effects as mentioned above.
C. "This medication is given to help with your depression."
This statement is incorrect. Benztropine is not indicated for the treatment of depression.
D. "Benztropine is used to counteract your tachycardia."
This statement is incorrect. Benztropine is not used to treat tachycardia (fast heart rate). It is specifically used for extrapyramidal side effects related to antipsychotic medications.
Correct Answer is B
Explanation
A. "You should leave your partner if you feel your life is in danger."
While leaving an abusive relationship is often necessary for safety, this statement might oversimplify a complex situation. Safety planning should be individualized and may involve various steps, not just immediate departure.
B. "You do not deserve to live in fear of your partner."
This statement validates the client's feelings and emphasizes their right to live without fear. It empowers the client and encourages self-worth.
C. "You need to tell your partner that you intend to leave the relationship."
Telling an abusive partner about the intention to leave can escalate the situation and put the client at risk. Safety planning usually involves not disclosing plans until the client is in a safe environment.
D. "It is important to learn to diffuse your partner's anger."
This statement places the responsibility for the abusive behavior on the victim, which is not appropriate. Victims of abuse are not responsible for the actions of their abusers. The focus should be on their safety and well-being.
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