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. Leading a group discussion with several clients who have schizophrenia and are dealing with tardive dyskinesia: This activity involves providing support and education to individuals already experiencing a mental health condition and its associated complications. It falls under tertiary prevention, which focuses on minimizing the impact of established disease through treatment and rehabilitation.

B. Screening college students who demonstrate manifestations of depressive disorder: Screening individuals for depressive disorder symptoms, especially in a population known to be at risk (e.g., college students), aims to identify mental health issues early and intervene promptly. This falls under secondary prevention, which involves early detection and treatment to prevent the progression of a condition.

C. Training volunteers in an adult day care facility to communicate effectively with clients who have cognitive impairments: This activity focuses on improving communication and interaction skills with clients who have cognitive impairments. It falls under tertiary prevention, aiming to improve the quality of life and function of individuals already affected by cognitive impairment.

D. Teaching personal coping skills to a group of adults whose parents have Alzheimer's disease: This activity aims to empower individuals with coping skills to manage the stress and challenges associated with having a parent with Alzheimer's disease. It falls under tertiary prevention, focusing on minimizing the negative consequences of an already existing condition.

A. "Has a family member indicated that you should cut down on your drinking?” B. “Have you had a glass of wine in the last week?” C. “Do you drink alcohol with your friends?” D. "Do you enjoy drinking alcohol?”

Correct Answer is A

Explanation

A. "Has a family member indicated that you should cut down on your drinking?”: This question assesses whether there have been any external concerns or criticisms related to the client's alcohol consumption, which is a common feature in alcohol use disorder.

B. “Have you had a glass of wine in the last week?”: While this question assesses recent alcohol consumption, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

C. “Do you drink alcohol with your friends?”: This question addresses social drinking behavior but does not specifically focus on the potential for alcohol use disorder or problematic drinking patterns.

D. "Do you enjoy drinking alcohol?”: While enjoyment of alcohol may be relevant to the overall assessment, it does not specifically address problematic drinking patterns or consequences associated with alcohol use disorder.

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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 mental health nurse is providing preventive care for a group of clients in the community. Which of the following actions by the nurse demonstrates a secondary prevention strategy?

Correct Answer is B

Explanation

A nurse is caring for a client who reports a history of frequent alcohol consumption. Which of the following questions should the nurse ask when screening for alcohol use disorder?

Correct Answer is A

Explanation

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