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 A

Explanation

A. A nurse did not clarify a client's prescription that was difficult to read resulting in a medication error: This scenario describes a medication error due to the nurse's failure to exercise reasonable care by not clarifying a difficult-to-read prescription. This constitutes negligence, making it an example of an unintentional tort.

B. A nurse posted private information on social media about a client who has substance use disorder: This scenario involves a breach of confidentiality, which is a violation of the client's privacy rights. However, it is considered an intentional tort (specifically, invasion of privacy) rather than an unintentional tort.

C. A nurse placed a client in mechanical restraints without containing a prescription, resulting in injury: This scenario describes a failure to follow proper procedures (restraining a client without a prescription), resulting in harm to the client. This also constitutes negligence, making it an example of an unintentional tort.

D. A nurse threatened a client with physical harm after the client became verbally abusive to staff members: This scenario involves the nurse's intentional act of threatening physical harm to the client, which constitutes an intentional tort (assault).

A. Slow speech B. Rapid mood changes C. Hallucinations D. Unaltered level of consciousness E. Restlessness

Correct Answer is ["B","C","E"]

Explanation

A. Delirium often causes disorganized thinking and communication, but speech can be either slow or rapid and incoherent. Slow speech is not a definitive sign of delirium.

B.Rapid mood changes are commonly seen in delirium. Clients may exhibit sudden shifts in mood, such as becoming agitated, anxious, irritable, or euphoric, often without apparent cause.

C.Hallucinations, both visual and auditory, are common manifestations of delirium. Clients may perceive things that are not present, hear voices, or experience other sensory distortions.

D.Delirium typically involves an altered level of consciousness, which can range from hyperalertness to lethargy. An unaltered level of consciousness is not characteristic of delirium.

E.Restlessness, agitation, and an inability to sit still are frequent manifestations of delirium. Clients may exhibit hyperactivity, fidgeting, pacing, or attempting to remove medical devices or clothing.

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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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