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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. Buprenorphine:
Buprenorphine is a medication used in the treatment of opioid dependence. It acts on the same receptors in the brain as opioids, helping to reduce cravings and withdrawal symptoms in individuals recovering from opioid addiction. It is not typically used for alcohol withdrawal.

B. Naltrexone:
Naltrexone is an opioid receptor antagonist used in the treatment of alcohol dependence. It works by blocking the effects of endorphins, the body's natural opioids. In the context of alcohol dependence, it reduces the rewarding effects of alcohol and decreases the craving for alcohol. Naltrexone can be prescribed for individuals experiencing acute manifestations of alcohol withdrawal as part of a comprehensive treatment plan.

C. Disulfiram:
Disulfiram is a medication that causes unpleasant symptoms (such as nausea, vomiting, and flushing) when alcohol is consumed. It works as a deterrent, discouraging individuals from drinking alcohol by creating a negative reaction. Disulfiram is used as a part of comprehensive alcohol treatment programs to help maintain abstinence. It is not typically used for acute alcohol withdrawal symptoms.

D. Bupropion:
Bupropion is an antidepressant medication that is also used to aid smoking cessation. It helps reduce withdrawal symptoms and the urge to smoke. While it is not used specifically for alcohol withdrawal, individuals with alcohol dependence often have higher rates of tobacco use. Bupropion might be prescribed to address both smoking cessation and depressive symptoms in individuals with alcohol dependence, but it does not directly address alcohol withdrawal.

A. "Talking about the traumatic experience is recommended." B. "Response prevention is an effective treatment for PTSD." C. "You should try to limit the number of hours that you sleep each day." D. "Avoiding stimull that trigger memories of the trauma can help you overcome your PTSD."

Correct Answer is D

Explanation

A. "Talking about the traumatic experience is recommended."
This statement is generally correct. Many therapeutic approaches for PTSD, such as cognitive-behavioral therapy (CBT) and exposure therapy, involve talking about the traumatic experience in a controlled and supportive environment. However, the timing and method of discussing the trauma should be guided by a mental health professional.

B. "Response prevention is an effective treatment for PTSD."
This statement is incorrect. Response prevention is a therapeutic technique often used in the treatment of anxiety disorders like obsessive-compulsive disorder (OCD). It involves preventing the usual response to a trigger. However, for PTSD, exposure therapy, cognitive restructuring, and EMDR (Eye Movement Desensitization and Reprocessing) are more common therapeutic approaches.

C. "You should try to limit the number of hours that you sleep each day."
This statement is incorrect. Adequate sleep is crucial for overall mental and physical health, and disrupting sleep patterns can worsen symptoms of PTSD. Sleep disturbances are common in PTSD, and part of managing the disorder often involves addressing sleep problems.

D. "Avoiding stimuli that trigger memories of the trauma can help you overcome your PTSD."
This statement is generally correct. Avoiding triggers that bring back memories of the trauma is a common coping strategy. However, while avoidance might provide short-term relief, it's not a long-term solution. Evidence-based therapies often involve confronting and processing these triggers in a safe and controlled way, under the guidance of a therapist.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing new prescriptions for a client who is experiencing acute manifestations of alcohol withdrawal. Which of the following medications should the nurse expect the provider to prescribe for this client?

Correct Answer is B

Explanation

A nurse is providing teaching about disorder management for a client who has posttraumatic stress disorder (PTSD). Which of the following statements should the nurse include in the teaching?

Correct Answer is D

Explanation

A nurse is planning overall strategies to address problems for a client who has borderline personality disorder. Which of the following strategies is the priority for the nurse to incorporate in the plan of care?

A nurse is planning care for an adolescent who has autism spectrum disorder. Which of the following outcomes should the nurse include in the plan of care?

A nurse is leading a therapy session for a group of adolescent clients. Which of the following statements should the nurse identify as an adaptive use of ego defense mechanisms?

A nurse is caring for a client who is prescribed massage therapy to treat panic disorder. The client states, "I can't stand to be touched by another person." Which of the following responses should the nurse make?

A nurse is preparing to meet with a client who was recently admitted to an outpatient mental health facility. Which of the following actions should the nurse plan to take during the working phase of the nurse-client relationship?

A nurse is caring for a client who has alcohol use disorder and is experiencing acute withdrawal. Which of the following medications should the nurse expect to administer first?

A nurse is caring for a client who is involuntarily admitted for major depressive disorder and refuses to take a prescribed oral antianxiety medication. Which of the following actions should the nurse take?

A nurse in an acute care mental health facility is creating a plan of care for a newly admitted client. Which of the following interventions should the nurse plan to include in the working phase of the nurse-client relationship?