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. Withholding a prescribed medication that is causing adverse effects for the client
The principle of nonmaleficence, often summarized as "do no harm," emphasizes the nurse's duty to prevent harm and to remove existing harm. If a medication prescribed to a client is causing adverse effects, the nurse should withhold the medication to prevent harm to the client.
B. Educating the client about legal rights concerning treatment
Educating the client about their legal rights falls under providing information and ensuring the client's autonomy but does not directly address the principle of non-maleficence.
C. Providing the client with quality care regardless of ability to pay for treatment
Providing quality care regardless of the client's ability to pay is an ethical practice, but it aligns more with the principles of justice and beneficence rather than nonmaleficence.
D. Being truthful with the client about the manifestations of withdrawal
Being truthful and providing accurate information to the client about withdrawal symptoms is crucial, but it doesn't directly address the principle of nonmaleficence.
Correct Answer is B
Explanation
A. Reduced frequency of panic attacks:
ECT is not primarily used to treat panic attacks. It is more commonly employed for severe mood disorders such as major depressive disorder and bipolar disorder. While ECT might indirectly affect anxiety symptoms, its main focus is on mood stabilization and improvement of depressive symptoms.
B. Decreased feelings of hopelessness:
This is the correct choice. Decreased feelings of hopelessness, often accompanied by improved mood and reduced suicidal thoughts, indicate the effectiveness of ECT in treating severe depression. ECT is known for its rapid and significant impact on mood, leading to improvements in feelings of hopelessness and despair, which are common symptoms of severe depression.
C. Reduced frequency of seizures:
ECT itself induces controlled seizures under anesthesia as part of the treatment process. The goal of ECT is not to reduce seizures but to target specific mental health conditions, particularly severe mood disorders. ECT is not indicated for managing epilepsy or reducing the frequency of seizures related to neurological disorders.
D. Decreased fear of heights:
ECT is not a treatment specifically designed to address phobias or fear-related disorders such as acrophobia (fear of heights). It is primarily used for severe mental health conditions, especially mood disorders. While an individual's overall anxiety might improve with successful ECT treatment, its direct effect on specific phobias like fear of heights is not a primary indication for the therapy.
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