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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Insisting on having their own way when playing with friends is a common behavior among children and is not necessarily related to a traumatic experience. It could be a sign of a strong personality or a phase of development where the child is learning about power and control.
Choice B rationale
Crying because they are the smallest child in their class is more likely related to self-esteem or body image issues. This behavior is not typically associated with experiencing a traumatic event like a house fire.
Choice C rationale
Being rude to siblings when things do not go their way is a common behavior among children and is not necessarily indicative of a traumatic experience. It could be a sign of frustration or difficulty managing emotions.
Choice D rationale
Making small fires in the backyard could be a sign that the child is trying to make sense of or reenact the traumatic experience of their house being destroyed by a wildfire. This behavior is a cause for concern and should be addressed with professional help.
Correct Answer is A
Explanation
Choice A rationale
The cortico-striato-thalamo-cortical circuit (CSTC) of the brain is associated with feelings of fear. Anxiety disorders are characterized by an overactivation of this circuit, leading to excessive fear responses14.
Choice B rationale
The amygdala-centered (ACC) circuit of the brain is not typically associated with feelings of apprehension. The ACC is more commonly associated with processing emotions and fear learning14.
Choice C rationale
The cortico-striato-thalamo-cortical circuit (CSTC) of the brain is not specifically associated with phobias. While this circuit plays a role in fear responses, it is not specific to phobic responses14.
Choice D rationale
The amygdala-centered (ACC) circuit of the brain is associated with feelings of panic. However, it is not the only brain circuit involved in anxiety. Other circuits, including the CSTC, also play important roles14.
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