A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?

Document in the client's medical record every 15 min.

Offer toileting to the client every 4 hr.

Remove the restraint when the client falls asleep.

Request that the provider write an as-needed prescription for restraints.

Answer and Explanation

The Correct Answer is A

A. Documenting in the client's medical record every 15 minutes is essential to monitor the client's status, including physical and psychological well-being, while in restraints. Accurate documentation ensures that any changes or responses to the intervention are recorded and communicated to other healthcare providers.
B. Offering toileting to the client every 4 hours may be necessary depending on the client's

individual needs, but it does not address the immediate need for monitoring the client's safety and well-being while restrained.
C. Removing the restraint when the client falls asleep is not appropriate without a healthcare provider's order. Restraints should only be removed based on a specific criteria set forth by
institutional policies or as directed by the healthcare provider.

D. Requesting an as-needed prescription for restraints is not appropriate. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a healthcare provider's assessment and orders.

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Correct Answer is C

Explanation

A. The ability to remove her own socks demonstrates motor skills development and independence, which are appropriate for an 18-month-old toddler.
B. Having a security blanket is a common comfort item for toddlers and is not typically a cause for concern.
C. The ability to say four words is below the expected language development milestone for an 18-month-old toddler, who should typically be saying 10 or more words by this age. Therefore, this finding should be reported to the provider for further evaluation.
D. Throwing a ball without falling demonstrates gross motor skills development, which is appropriate for an 18-month-old toddler.

A. "A nurse will insert an IV prior to starting the test." B. "You should have nothing to eat or drink for 4 hours prior to the test." C. "You should expect the test to take a minimum of 2 hours." D. "You will be asked to press a button when you feel your baby move." E. "You will be asked to press a button when you feel your baby move."

Correct Answer is D

Explanation

A. Inserting an IV is not necessary for a nonstress test, which is a noninvasive procedure.
B. Fasting is not required for a nonstress test, as it does not involve any invasive procedures.
C. C. A nonstress test typically takes around 20 to 30 minutes to complete, not a minimum of 2 hours.
D. This is the correct answer. During a nonstress test, the client is asked to press a button every time they feel their baby move. This helps correlate fetal movements with changes in fetal heart rate, providing information about fetal well-being.

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A nurse is caring for a client who is in mechanical restraints after becoming violent with a staff member. Which of the following actions should the nurse take?

Nursing Test Bank

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