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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. This statement describes a visual hallucination (seeing spiders crawling), not a command hallucination. Visual hallucinations involve seeing things that are not actually present.

B. This statement reflects a delusion rather than a hallucination. Delusions are false beliefs that are firmly held despite evidence to the contrary. In this case, the belief in aliens and abduction is not related to hearing voices commanding actions.
C. This statement indicates a command hallucination. The client hears voices instructing them to stop eating. Command hallucinations often involve direct, imperative commands from voices that are perceived as real.
D. This statement reflects paranoia or fear of harm from others, which can be a common symptom in schizophrenia. However, it does not directly indicate a command hallucination.

A. "Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight." B. "People who have bulimia nervosa eat an average amount of food on a daily basis." C. "People who have bulimia nervosa are at risk for developing diabetes mellitus." D. "As long as a person is not vomiting after eating, they do not have bulimia nervosa."

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.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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