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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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Liraglutide 0.6 mg subcutaneously daily:
Liraglutide is a medication used to treat type 2 diabetes and obesity. It works by regulating blood sugar levels and reducing appetite. It has no direct relevance to the treatment of schizophrenia or psychosis. Schizophrenia is a mental health disorder, and antipsychotic medications are typically used to manage its symptoms.

B. Selegiline 6 mg transdermal patch daily:
Selegiline is primarily used to treat Parkinson's disease by enhancing the effects of dopamine in the brain. It is not indicated for schizophrenia or psychosis. While dopamine dysregulation is involved in both Parkinson's disease and schizophrenia, the mechanisms and treatments are different. Antipsychotic medications, not selegiline, are used to manage psychosis in schizophrenia.

C. Aripiprazole 400 mg IM every 4 weeks:
This is the correct choice. Aripiprazole is an atypical antipsychotic medication commonly used to treat schizophrenia and other psychotic disorders. The intramuscular (IM) formulation provides extended release, making it suitable for clients who may have difficulty adhering to daily oral medications. It helps manage psychosis, a common symptom of schizophrenia.

D. Lithium 600 mg PO three times per day:
Lithium is a mood stabilizer commonly used to treat bipolar disorder by preventing or reducing the intensity of manic episodes. It is not a first-line treatment for schizophrenia or psychosis. Antipsychotic medications are the primary choice for managing the symptoms of psychosis in schizophrenia. Lithium is not typically used to address the hallucinations and delusions associated with schizophrenia.

A. Instruct the client to consume a low-sodium diet to decrease hand tremors. B. Teach the client to take the lithium in a single daily dose C. Contact the provider for a possible decrease in the lithium dosage. D. Encourage the client to take naproxen sodium to decrease tremors.

Correct Answer is C

Explanation

A. Instruct the client to consume a low-sodium diet to decrease hand tremors:
While maintaining a stable sodium intake is important for individuals taking lithium to avoid fluctuations in lithium levels, a low-sodium diet is not specifically indicated to address hand tremors caused by lithium. Adjusting sodium levels is more about maintaining a consistent intake to stabilize lithium levels over time.

B. Teach the client to take the lithium in a single daily dose:
Lithium is often prescribed in divided doses to maintain stable blood levels throughout the day and minimize side effects. However, the dosing regimen (once or multiple times a day) is usually determined by the healthcare provider based on the individual's needs. Changing the dosing frequency is not the primary intervention for managing hand tremors.

C. Contact the provider for a possible decrease in the lithium dosage:
Hand tremors are a common side effect of lithium. If a client is experiencing bothersome side effects within the therapeutic range, the appropriate action is to contact the healthcare provider. The provider can assess the situation, possibly adjust the dosage, or explore other management options to alleviate the tremors while maintaining the therapeutic effect of the medication.

D. Encourage the client to take naproxen sodium to decrease tremors:
Encouraging the client to take naproxen sodium or any other nonsteroidal anti-inflammatory drug (NSAID) is not recommended when the client is on lithium therapy. NSAIDs can interact with lithium, potentially leading to increased lithium levels and toxicity. Combining these medications should be avoided.

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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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Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer medications to a newly admitted client who has schizophrenia and is experiencing psychosis. Which of the following medications should the nurse plan to administer?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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