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 D

Explanation

A. Washing the newborn's head under a stream of running water is not recommended, as it could startle the newborn or lead to water entering the ears or eyes. Instead, the head should be washed gently using a damp cloth or sponge.

B. Bathing the newborn within 30 minutes after a feeding is not advisable. This could increase the risk of regurgitation or discomfort during the bath. It is better to bathe the newborn when they are calm and not immediately after feeding.

C. Starting the bath by washing the diaper area first is incorrect. The newborn’s face and head should be washed first to avoid spreading bacteria from the diaper area to other parts of the body.

D. The bath water should be 100 to 103 degrees Fahrenheit, as this is a safe and comfortable temperature for the newborn. It prevents chilling or burns and ensures the bath is soothing for the baby.

A. Call EMS if a seizure lasts 5 min or more. B. Restrain the child at the onset of the seizure. C. Offer the child a bubble bath every evening. D. Place the child in a prone position during the seizure.

Correct Answer is A

Explanation

A. This is the correct answer. Seizures lasting longer than 5 minutes can be indicative of status epilepticus, a medical emergency requiring immediate intervention.
B. Restraint during a seizure can cause injury to the child and is not recommended. Instead, it's important to ensure the child's safety by removing nearby objects and gently guiding them to the floor if possible.
C. Offering a bubble bath every evening is not relevant to seizure care and does not contribute to the child's safety or well-being.
D. Placing the child in a prone position during a seizure can obstruct the airway and increase the risk of aspiration. The child should be placed in a lateral recumbent position to maintain an open airway and prevent injury.

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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?

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