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 D
Explanation
A. Increased time sleeping:
Increased time sleeping alone is not a specific or direct indicator of PTSD. However, changes in sleep patterns are common in individuals with PTSD, with symptoms like nightmares, insomnia, and disturbances in sleep. These disturbances can lead to increased time in bed, but this alone is not a definitive sign of PTSD.
B. Inability to express empathy:
Inability to express empathy is a complex issue and could be related to various emotional or psychological factors. While people with PTSD can experience difficulties in interpersonal relationships, including issues with empathy, this alone is not a specific indicator of the disorder. PTSD primarily involves symptoms related to re-experiencing trauma, avoidance, negative mood changes, and arousal symptoms.
C. Auditory hallucinations:
Auditory hallucinations, which involve hearing voices or sounds that others do not, are not typically associated with PTSD. This symptom is more commonly linked to conditions like schizophrenia or other psychotic disorders, but it is not specific to PTSD.
D. Difficulty concentrating:
Difficulty concentrating is a common and well-recognized symptom of PTSD. Individuals with PTSD often struggle with focus, memory, and attention due to the intrusion of traumatic thoughts and memories. This symptom can significantly impact their daily functioning and is one of the hallmark features of the disorder.
Correct Answer is C
Explanation
A. Summarize the objectives the client achieved during the relationship:
This intervention is more appropriate for the termination phase of the nurse-client relationship. During termination, the nurse summarizes the progress made, goals achieved, and skills learned during the therapeutic relationship. This helps both the nurse and the client reflect on the journey and celebrate accomplishments.
B. Present issues regarding confidentiality:
Discussing confidentiality is crucial and typically occurs in the orientation phase of the nurse-client relationship. Establishing trust and clarifying the boundaries of confidentiality early in the relationship helps the client feel secure and promotes open communication. This choice is relevant during the initial stages of the therapeutic relationship.
C. Promote the client's problem-solving skills:
This is the correct choice for the working phase of the nurse-client relationship. In this phase, the focus is on active problem-solving, exploring feelings and thoughts, and encouraging the client to develop coping strategies. The nurse supports the client in identifying problems, generating solutions, and implementing effective strategies. Promoting the client's problem-solving skills is a central aspect of therapeutic work during this phase.
D. Identify the responsibilities of the client and nurse:
Clarifying the responsibilities of both the client and nurse is essential to establish clear roles and expectations. This usually occurs in the orientation phase. During this phase, the nurse explains the purpose of the therapeutic relationship, the roles of both parties and the boundaries of the nurse-client interaction. Establishing clear responsibilities helps create a foundation for a respectful and effective therapeutic alliance.
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