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 hr of application of restraints

Answer and Explanation

The Correct Answer is C

A. Documentation should occur every 15-30 minutes to ensure the client's safety and to assess the need for continuing or removing the restraints.

B. Keep the client in restraints until the prescription expires: Restraints should be used for the shortest duration necessary to ensure the safety of the client and others. Keeping the client restrained until the prescription expires without reevaluation may not align with best practices for restraint use.

C. Conducting a debriefing with the unit staff is crucial to evaluate the situation, discuss the events leading up to the use of restraints, and develop strategies to prevent the need for future restraint use. This helps ensure the safety and well-being of the client and others, as well as improve care practices.

D.Typically, the evaluation should occur within 1-4 hours depending on the facility's policy and the urgency of the situation.

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Correct Answer is B

Explanation

A. “ECT contraindicated in clients who have psychotic symptoms.”: This statement is incorrect. ECT can be used to treat various mental health conditions, including severe depression with psychotic features. It is not contraindicated solely based on the presence of psychotic symptoms.

B. "ECT is delivered through electrodes attached to the head.”: This statement is accurate. Electroconvulsive therapy (ECT) involves the delivery of electrical currents to the brain through electrodes placed on the scalp. These electrodes are positioned to target specific areas of the brain.

C. “ECT cannot be administered to clients who have suicide ideation”: This statement is incorrect. ECT can be considered as a treatment option for individuals with severe depression, including those with suicidal ideation or behavior. It can be effective in rapidly alleviating symptoms and reducing suicide risk in some cases.

D. “ECT is conducted under regional anesthesia.”: This statement is incorrect. Electroconvulsive therapy (ECT) is typically performed under general anesthesia to ensure the client's comfort and safety during the procedure. Regional anesthesia is not commonly used for ECT.

A. The client has a serotonin deficiency B. The client has acute bronchitis C. The client has an elevated calcium level D. The client is an only child

Correct Answer is A

Explanation

A. The client has a serotonin deficiency

This choice suggests a biological risk factor for major depressive disorder (MDD). Serotonin is a neurotransmitter associated with mood regulation, and alterations in its levels or function can contribute to the development of depressive symptoms. A deficiency in serotonin is considered a significant biological risk factor for MDD.

B. The client has acute bronchitis

Acute bronchitis, an inflammation of the bronchial tubes typically caused by viral infections, is not directly associated with major depressive disorder. While physical health issues can impact mental health and exacerbate depressive symptoms, acute bronchitis is not a recognized risk factor for MDD.

C. The client has an elevated calcium level

Elevated calcium levels are not typically considered a risk factor for major depressive disorder. While imbalances in electrolytes like calcium can have physiological effects on the body, they are not directly linked to the development of depression.

D. The client is an only child

Being an only child is a demographic characteristic and is not considered a direct risk factor for major depressive disorder. While family dynamics and relationships can influence mental health, being an only child alone is not causally related to the development of depression.

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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 preparing to teach a client who has major depressive disorder and is scheduled to undergo electroconvulsive therapy (ECT) Which of the following statements should the nurse include in the teaching?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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