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 B

Explanation

Choice A reason: Midazolam is a benzodiazepine used primarily for sedation, anxiety relief, and anesthesia. It is not used as a first-line treatment for major depressive disorder.

Choice B reason: Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) commonly prescribed as a first-line treatment for major depressive disorder. SSRIs work by increasing the levels of serotonin in the brain, which can help improve mood and alleviate depressive symptoms.

Choice C reason: Cyclobenzaprine is a muscle relaxant used to relieve muscle spasms. It is not indicated for the treatment of major depressive disorder.

Choice D reason: Valproic acid is primarily used as a mood stabilizer and anticonvulsant. It is not typically used as a first-line treatment for major depressive disorder, although it may be used in cases of bipolar disorder.

A. Hallucinations B. Depression C. Delusions D. Catatonia E. Tinnitus

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason:

Hallucinations, particularly if they are distressing or command hallucinations, can increase the risk of suicide attempts.

Choice B reason:

Depression is a major risk factor for suicide. Clients with a history of depression are at higher risk for attempting suicide again.

Choice C reason:

Delusions, especially those that are paranoid or persecutory, can contribute to suicidal thoughts and behaviors.

Choice D reason:

Catatonia, a state of psychomotor disturbance, can be associated with severe depression and increase the risk of suicide.

Choice E reason:

Tinnitus, while distressing, is not typically a direct risk factor for suicide attempts. It may contribute to overall distress but is not a primary indicator of suicide risk.

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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 nurse is caring for a client who has a new diagnosis of major depressive disorder. Which of the following medications should the nurse expect the provider to prescribe to the client as a first-line treatment?

Correct Answer is B

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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