A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Document the client’s behavior once every hour.

Keep the client in restraints until the prescription expires.

Conduct a debriefing regarding the client with the unit staff.

Request an evaluation of the client within 12 hours of application of restraints.

Answer and Explanation

The Correct Answer is D

Choice A reason: Documenting the client’s behavior once every hour is important for monitoring the client’s condition and ensuring their safety. However, it is not the most immediate action to take after applying restraints.

Choice B reason: Keeping the client in restraints until the prescription expires is not appropriate. Restraints should be used for the shortest duration necessary and should be removed as soon as the client is no longer a threat to themselves or others.

Choice C reason: Conducting a debriefing with the unit staff is important for reviewing the incident and planning future care. However, it is not the immediate action required after applying restraints.

Choice D reason: Requesting an evaluation of the client within 12 hours of applying restraints is crucial. This ensures that the client’s condition is reassessed, and the need for continued restraints is evaluated. It also helps in planning further interventions to manage the client’s aggressive behavior.

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Correct Answer is D

Explanation

Choice A reason:

An illusion is a misinterpretation of a real external stimulus. The client’s statement does not indicate a misinterpretation of reality but rather a direct expression of intent to harm themselves.

Choice B reason:

A hallucination is a perception of something that is not present, such as hearing voices or seeing things that are not there. The client’s statement does not suggest they are experiencing a hallucination but rather expressing a desire to self-harm.

Choice C reason:

Attention-seeking behavior involves actions taken to gain attention from others. While the client’s statement may draw attention, it is more indicative of a serious risk of self-harm rather than merely seeking attention.

Choice D reason:

Self-mutilation refers to deliberate self-injury without suicidal intent. The client’s statement about using a pen to cut the pain out of their chest indicates a risk of self-harm, which requires immediate intervention to ensure their safety.

A. “These clients can receive packages after they are privately inspected by security.” B. “These clients cannot be considered for a research study.” C. “These clients can vote in local and federal elections.” D. “These clients cannot refuse their prescribed antipsychotic medications.”

Correct Answer is C

Explanation

Choice A reason:

While clients may receive packages, this statement does not specifically address their rights. The focus should be on their fundamental rights and freedoms.

Choice B reason:

Clients who are involuntarily admitted can be considered for research studies, provided they give informed consent and the study is ethically approved.

Choice C reason:

Clients who are involuntarily admitted retain their right to vote in local and federal elections. This is a fundamental right that is not lost due to their admission status.

Choice D reason:

Clients who are involuntarily admitted still have the right to refuse medications, including antipsychotics, unless there is a court order or emergency situation that mandates treatment.

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A nurse is caring for a client who is aggressive toward other clients and has been placed in wrist restraints. After obtaining a prescription for restraints from the provider, which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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