A nurse is caring for a client who is combative and requires wrist restraints. Which of the following actions should the nurse take?

Use a quick-release tie to restrain the client.

Renew the restraint prescription every 48 hr.

Attach the restraints to the side rail of the client's bed.

Maintain 1 fingerbreadth between the restraint and the client's skin.

Answer and Explanation

The Correct Answer is A

Choice A reason: Using a quick-release tie for restraints ensures that the nurse can quickly and easily release the client in case of an emergency. Quick-release ties are designed to provide safety and convenience, allowing healthcare providers to promptly respond to the client's needs without compromising safety. This method reduces the risk of injury to both the client and the healthcare team.

Choice B reason: Restraint prescriptions typically need to be renewed more frequently than every 48 hours, often within 24 hours. The exact duration depends on the facility's policy and regulatory guidelines. Regular assessment of the need for restraints and timely renewal of the prescription ensure that restraints are used appropriately and only as long as necessary.

Choice C reason: Attaching restraints to the side rail of the client's bed is unsafe and inappropriate. Restraints should be attached to a non-movable part of the bed frame to prevent the client from injuring themselves if the side rail is moved. Securing restraints to a stable part of the bed ensures better control and reduces the risk of harm.

Choice D reason: While maintaining some space between the restraint and the client's skin is important to prevent circulation issues, the guideline typically suggests maintaining two fingers' breadth between the restraint and the client's skin, not one. This ensures adequate circulation and reduces the risk of injury or skin breakdown.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Delirium is characterized by an acute onset, typically developing over hours to a few days. It is a sudden change in mental status that differs from conditions like dementia, which have a gradual onset. Therefore, gradual onset is not a characteristic finding of delirium.

Choice B reason: Impaired judgment is a common finding in delirium. Clients with delirium often have fluctuating levels of consciousness, attention deficits, and disorganized thinking, all of which can contribute to poor judgment. This cognitive impairment can lead to unsafe behaviors and difficulty in making decisions.

Choice C reason: Difficulty swallowing, or dysphagia, is not typically associated with delirium. Dysphagia is more often related to neurological conditions such as stroke, Parkinson's disease, or other disorders affecting the muscles involved in swallowing. While clients with delirium may have various physical symptoms due to underlying causes, difficulty swallowing is not a direct symptom of delirium itself.

Choice D reason: Slowed, flat speech is not a typical finding in delirium. Clients with delirium may exhibit rapid, incoherent, or disorganized speech due to their altered mental state. Slowed, flat speech is more commonly seen in conditions like depression or certain types of dementia rather than in acute delirium.

A. Unable to make simple decisions B. Enjoys spending time alone C. Exhibits extreme perfectionism D. Displays confrontational behavior

Correct Answer is A

Explanation

Choice A reason: Individuals with dependent personality disorder often struggle with making simple decisions without excessive advice and reassurance from others. They have a strong need for others to take responsibility for major areas of their lives and can feel helpless when alone. This indecisiveness is a hallmark of the disorder and stems from their lack of self-confidence and reliance on others for guidance and support.

Choice B reason: Enjoying spending time alone is not a characteristic of dependent personality disorder. In fact, individuals with this disorder typically avoid being alone and seek constant companionship and support from others. They may go to great lengths to be taken care of and may feel uncomfortable or distressed when they are by themselves.

Choice C reason: Extreme perfectionism is more commonly associated with obsessive-compulsive personality disorder (OCPD) rather than dependent personality disorder. While individuals with dependent personality disorder may exhibit some perfectionistic traits, it is not a defining characteristic of the disorder. The primary issues in dependent personality disorder revolve around dependency and fear of abandonment.

Choice D reason: Confrontational behavior is not typical of dependent personality disorder. Individuals with this disorder tend to be passive, submissive, and avoidant of conflict. They are more likely to acquiesce to others' demands and avoid confrontations in order to maintain relationships and ensure they are taken care of. This behavior contrasts with the confrontational tendencies seen in other personality disorders.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nurse is caring for a client who is combative and requires wrist restraints. 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 delirium. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A charge nurse is reinforcing teaching with a newly licensed nurse about the clinical manifestations of dependent personality disorder. Which of the following manifestations should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is collecting data from a client who reports cessation of nicotine use. Which of the following manifestations should the nurse expect? (Select all that apply.)

A nurse is reinforcing teaching with a client who is to receive electroconvulsive therapy. Which of the following statements should the nurse include in the teaching?

A charge nurse overhears a staff nurse talking to a nurse from another unit in the hallway. The staff nurse says, "I heard that Mr. Smith was admitted for a suicide attempt." Which of the following responses should the charge nurse make?

A nurse is participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?

A nurse is working with a group of clients during group therapy. For which of the following client disorders will setting limits serve as an appropriate behavioral management technique?

A nurse is collecting data from a client who is taking amitriptyline. Which of the following findings should the nurse report to the provider as an adverse effect of the medication?

A nurse is caring for a client who has chronic alcohol use disorder. Which of the following laboratory findings should the nurse monitor to evaluate the client's nutritional status?

A nurse is caring for a client who has agreed to a verbal safety contract following a self-mutilation attempt. Which of the following behaviors indicates that the contract has been effective?