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 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.

A. Provide additional attention to the client. B. Apply mechanical restraints before administering medication. C. Obtain a verbal contract from the client. D. Limit staff members who work with the client.

Correct Answer is C

Explanation

Choice A reason: Providing additional attention to the client can sometimes reinforce negative behaviors in individuals with borderline personality disorder. It is important to balance attention with promoting independence and self-regulation.

Choice B reason: Applying mechanical restraints before administering medication is not a standard practice and can be considered unethical and harmful. Restraints should only be used as a last resort when there is an immediate risk of harm to the client or others.

Choice C reason: Obtaining a verbal contract from the client is a therapeutic intervention that can help manage self-mutilation risks. This contract involves the client agreeing to communicate with staff before engaging in self-harm, which can help in developing trust and promoting safety.

Choice D reason: Limiting staff members who work with the client can help provide consistency and stability, which is beneficial for individuals with borderline personality disorder. However, it is not the primary intervention for preventing self-mutilation.

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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

A charge nurse is providing education to a group of newly licensed nurses about the rights of clients who are involuntarily admitted. Which of the following responses indicates understanding of the teaching?

Correct Answer is C

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Correct Answer is C

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