A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior. Which of the following actions should the nurse take?
Keep staff interactions with the client to a minimum.
Provide range-of-motion exercises to all extremities every 2 hr.
Request the provider renew the prescription in 24 hr.
Document the client's behavior in the medical record every 1 hr.
The Correct Answer is C
A. Keeping staff interactions to a minimum may not be beneficial as the client might require regular monitoring and interaction to assess their condition and needs.
B. When a client is restrained, it's crucial to prevent complications such as muscle stiffness and joint contractures. Range-of-motion exercises help maintain circulation, prevent discomfort, and preserve joint mobility. However, this is not the most important action.
C. Restraints should only be used when absolutely necessary and prescribed by a provider. In many jurisdictions and healthcare facilities, the use of restraints requires a specific order that must be renewed periodically (often every 24 hours). This practice ensures that the need for restraints is continually reassessed and that they are not used longer than necessary.
D. Accurate and frequent documentation is essential when a client is restrained. Documentation should include the client's behavior, physical assessments, interventions provided (such as medication administration or hygiene care), and responses to interventions. However, this is not the most important action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Unlike anorexia nervosa, where individuals typically appear underweight, people with bulimia nervosa often maintain a body weight within the normal or even overweight range. This can make it challenging to identify based on physical appearance alone, as individuals may hide their binge-eating and purging behaviors.
B. Individuals with bulimia nervosa often engage in episodes of binge-eating, during which they consume large amounts of food in a short period and feel a loss of control over their eating. This is followed by compensatory behaviors such as self-induced vomiting, misuse of laxatives or diuretics, fasting, or excessive exercise to prevent weight gain.
C. Bulimia nervosa does not directly increase the risk of developing diabetes mellitus. However, the binge-eating episodes characteristic of bulimia can lead to metabolic disturbances and insulin resistance over time. This can potentially increase the risk of developing type 2 diabetes in individuals who are predisposed or have other risk factors.
D. While self-induced vomiting is a common purging method in bulimia nervosa, there are other ways individuals may attempt to compensate for binge-eating episodes, such as excessive exercise, fasting, or misuse of laxatives or diuretics. The key diagnostic criteria for bulimia nervosa include recurrent episodes of binge-eating and inappropriate compensatory behaviors to prevent weight gain.
Correct Answer is B
Explanation
A. This statement indicates that the client has abstained from alcohol while on haloperidol decanoate. This is a positive statement and shows compliance with recommendations, as alcohol can interact with medications and affect their effectiveness or cause adverse reactions. There is no immediate concern with this statement.
B. Haloperidol can increase sensitivity to sunlight (photosensitivity). Spending several hours outside gardening in the sun could potentially increase the risk of sunburn or other skin reactions due to photosensitivity. The nurse should address this statement by educating the client about the need to use sunscreen, wear protective clothing, and avoid prolonged sun exposure, especially during peak sunlight hours.
C. Regular monitoring of blood pressure is generally recommended for clients taking haloperidol, as it can occasionally cause hypotension (low blood pressure) as a side effect. Checking blood pressure once a week is a reasonable frequency, but the nurse should ensure that the client understands the signs and symptoms of hypotension and knows when to seek medical attention if blood pressure readings are abnormal.
D. Chewing sugar-free gum is generally not contraindicated while taking haloperidol. However, if the gum contains caffeine or other stimulants, it could potentially exacerbate certain side effects of the medication, such as tremors or restlessness. The nurse should inquire further about the type of gum being used and educate the client about potential interactions or side effects.
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