A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?

The client must be calm and cooperative.

The provider who prescribed the restraints must be present to assess the client before the restraints can be removed.

The client must verbalize remorse for their behavior.

The client only verbalizes anger toward the staff.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The client must be calm and cooperative. This is the most important criterion for removing physical restraints. Restraints are used to prevent patients from causing harm to themselves or others. Once the patient is calm and cooperative, it indicates that the risk of harm has decreased. The goal is always to use the least restrictive measures and to remove restraints as soon as possible.
Choice B rationale
The provider who prescribed the restraints must be present to assess the client before the restraints can be removed. This is not necessarily true. While a provider’s order is required to initiate restraints, the decision to remove them can often be made by the nurse based on their assessment of the patient.
Choice C rationale
The client must verbalize remorse for their behavior. This is not a requirement for removing restraints. The primary concern is the safety of the patient and others, not whether the patient expresses remorse.
Choice D rationale

The client only verbalizes anger toward the staff. If the client is still expressing anger, it may not be safe to remove the restraints. However, verbalizing anger alone is not a sufficient reason to keep a patient in restraints.

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Correct Answer is D

Explanation

Choice A rationale
While expressing empathy is important, this response does not demonstrate an understanding of the concept of historical trauma. Historical trauma refers to the cumulative emotional and psychological wounding of an individual or generation caused by a traumatic experience or event.

Choice B rationale
This response is not appropriate as it attempts to pinpoint the trauma to a specific time in the client’s life. The client is referring to a historical trauma that affected their ancestors and continues to impact their family.
Choice C rationale
This response is vague and does not address the client’s statement about the impact of historical trauma on their family.
Choice D rationale
This is the correct response. By stating that they understand the impact of historical trauma, the nurse acknowledges the long-term effects of traumatic events that occurred in the past and continue to affect the client’s family.

A. It is a gene variant that increases the risk for development of a specific mental illness. B. It is a gene variant that is responsible for an individual’s resilience to stress. C. It is a gene variant that is responsible for the development of a specific mental illness. D. It is a gene variant that determines an individual’s likelihood of recovering from mental illness.

Correct Answer is A

Explanation

Choice A rationale
A vulnerability gene is a gene variant that increases the risk for development of a specific mental illness. It does not guarantee that an individual will develop the illness, but it does increase their susceptibility.
Choice B rationale
A gene variant that is responsible for an individual’s resilience to stress is not typically referred to as a vulnerability gene. Resilience genes are thought to provide some protection against the development of mental illnesses.
Choice C rationale
A gene variant that is responsible for the development of a specific mental illness is not typically referred to as a vulnerability gene. While certain gene variants can increase the risk of developing a mental illness, they are usually not the sole cause. Mental illnesses are typically the result of a complex interplay of genetic, environmental, and psychological factors.
Choice D rationale

A gene variant that determines an individual’s likelihood of recovering from mental illness is not typically referred to as a vulnerability gene. Recovery from mental illness is influenced by a variety of factors, including the individual’s access to effective treatment, their level of social support, and their personal resilience.

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A nurse is caring for a client who is in physical restraints after demonstrating aggressive behavior. Which of the following criteria must be met before the nurse can remove the restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who states, “My mother and my mother’s mother have all been in abusive relationships. We believe this is because of what happened to our people 100 years ago with slavery.”. Which response by the nurse demonstrates understanding of the client’s trauma?

Correct Answer is D

Explanation

A nurse in an outpatient facility is teaching a client about the development of mental illness. Which of the following statements by the nurse describes the role of a vulnerability gene?

Correct Answer is A

Explanation

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