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:

Agreeing with the parent and assuming the situation will not happen again is not appropriate. It dismisses the potential risk to the child and does not address the seriousness of the situation.

Choice B reason:

Telling the parent to file charges against their partner is a strong directive that may not be appropriate without further understanding of the situation. It is important to gather more information before making such recommendations.

Choice C reason:

Stating that the situation is clearly child endangerment and immediately calling the police may escalate the situation without fully understanding the context. It is important to assess the situation thoroughly before taking such actions.

Choice D reason:

Expressing a desire to know more about what happened and offering to talk is an appropriate response. It allows the nurse to gather more information, assess the situation, and provide support to the parent and child.

A. Paranoid B. Histrionic C. Narcissistic D. Antisocial

Correct Answer is B

Explanation

Choice A reason:

Paranoid personality disorder is characterized by pervasive distrust and suspicion of others. Individuals with this disorder often believe that others are out to harm or deceive them, and they may be reluctant to confide in others due to fear that the information will be used against them. They may also bear grudges and be quick to perceive attacks on their character that are not apparent to others. This disorder does not typically involve attention-seeking behaviors or flirtatious and seductive actions.

Choice B reason:

Histrionic personality disorder is marked by a pattern of excessive emotionality and attention-seeking behavior. Individuals with this disorder often feel uncomfortable when they are not the center of attention and may engage in inappropriate sexually seductive or provocative behavior to draw attention to themselves. They may also exhibit rapidly shifting and shallow expressions of emotions, use their physical appearance to attract attention, and have a style of speech that is excessively impressionistic and lacking in detail. These characteristics align with the behaviors described in the scenario.

Choice C reason:

Narcissistic personality disorder involves a pervasive pattern of grandiosity, need for admiration, and a lack of empathy for others. Individuals with this disorder often have an inflated sense of their own importance and a deep need for excessive attention and admiration. They may exploit others to achieve their own ends and believe they are superior to others. While they do seek attention, their behaviors are more focused on achieving admiration and recognition rather than the flirtatious and seductive behaviors described in the scenario.

Choice D reason:

Antisocial personality disorder is characterized by a disregard for and violation of the rights of others. Individuals with this disorder may engage in deceitful, manipulative, or aggressive behavior and often have a history of criminal activity. They may also show a lack of remorse for their actions. This disorder does not typically involve attention-seeking behaviors or flirtatious and seductive actions.

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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

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Explanation

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