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 C

Explanation

Choice A rationale
Agoraphobia is characterized by a fear of being in situations where escape might be difficult or embarrassing, or help might not be available in the event of panic symptoms. This does not align with the child’s symptoms of not being able to speak in class or other social situations.
Choice B rationale
Generalized anxiety disorder is characterized by excessive, uncontrollable worry about a variety of topics and is not specific to social situations. The child’s symptoms are more specific to social situations, which does not align with generalized anxiety disorder.

Choice C rationale
Selective mutism is an anxiety disorder characterized by a consistent failure to speak in specific social situations in which there is an expectation for speaking, despite speaking in other situations. This aligns with the child’s symptoms of not being able to speak during class and other social situations.
Choice D rationale
Separation anxiety disorder is characterized by excessive fear or anxiety about separation from those to whom the individual is attached. The child’s symptoms do not indicate a fear of separation, but rather a fear of speaking in social situations.

A. Having a physical disability. B. Performing well in school. C. Having a family with a strong social support system. D. Having caregivers who have steady employment.

Correct Answer is A

Explanation

Choice A rationale

Having a physical disability can be considered an ACE as it can lead to increased stress, potential for bullying, and other negative experiences. Children with physical disabilities may face unique challenges that can contribute to the development of anxiety disorders.
Choice B rationale
Performing well in school is generally considered a positive experience and is not an ACE. Academic success can contribute to a child’s self-esteem and sense of accomplishment.
Choice C rationale
Having a family with a strong social support system is a protective factor against the development of anxiety disorders and is not considered an ACE. A strong support system can provide a child with resources, emotional support, and a sense of security.
Choice D rationale
Having caregivers who have steady employment is not considered an ACE. Steady employment can provide financial stability and reduce stress in the household, which can be protective against the development of anxiety disorders.

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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 child whose guardians report that the child consistently cannot speak during class and other social situations. Which of the following anxiety disorders should the nurse identify that the child is experiencing?

Correct Answer is C

Explanation

A nurse in an outpatient mental health clinic is discussing the development of anxiety-related disorders in children to a group of parents. The nurse should include that which of the following is an adverse childhood experience (ACE) that can contribute to the development of an anxiety disorder?

Correct Answer is A

Explanation

A nurse is caring for a patient who reports a recent increase in stressors. Which of the following concepts should the nurse use to develop necessary context to both understand and deliver nursing care for this patient?

A nurse is caring for a client who is worried about developing a mental health disorder due to their childhood experiences. Which of the following family characteristics is a protective factor against adverse childhood experiences?

A nurse is caring for a patient with post-traumatic stress disorder who is considering prolonged exposure therapy. The patient asks, “How does this therapy work?” Which of the following responses accurately describes this type of therapy?

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?

A nurse is assessing a 6-year-old child who has experienced violence at school. Which of the following strategies should the nurse use during their assessment of this client?

A nurse is caring for a client who is experiencing manifestations of anxiety. The nurse should recognize which of the following statements about the neurophysiologic manifestations of anxiety as correct?

A nurse is reviewing assessment findings for a 9-year-old child whose family home was destroyed in a wildfire. The nurse should identify that which of the following behaviors is related to the traumatic experience?

A nurse is screening children and adolescents for exposure to adverse childhood experiences (ACEs). Which of the following clients is considered to have experienced an ACE?