A nurse is caring for a school-age child who has conduct disorder and is in physical restraints after becoming physically aggressive toward other clients on the unit. Which of the following actions should the nurse take?
Keep the restraints on for a minimum of 1 hour.
Monitor the child's vital signs every 15 minutes.
Ask the provider to renew the prescription for the restraints every 24 hours.
Arrange an in-person evaluation by the child's provider within 2 hours of initiating restraints.
The Correct Answer is B
Choice A Reason:
Keeping the restraints on for a minimum of 1 hour is not a standard practice. The duration of restraint use should be based on the child's behavior and the need for safety, rather than a fixed time period. Restraints should be used for the shortest duration necessary to ensure safety and should be removed as soon as the child is no longer a threat to themselves or others.
Choice B Reason:
Monitoring the child's vital signs every 15 minutes is crucial when a child is in physical restraints. This frequent monitoring helps ensure the child's physical well-being and allows for the early detection of any adverse effects related to the use of restraints. It is important to assess the child's respiratory and cardiovascular status, as well as their overall comfort and safety.
Choice C Reason:
Asking the provider to renew the prescription for the restraints every 24 hours is important, but it is not the most immediate action required. Restraint orders should be reviewed regularly to ensure they are still necessary, but the priority is to monitor the child's condition closely while they are restrained.
Choice D Reason:
Arranging an in-person evaluation by the child's provider within 2 hours of initiating restraints is a good practice to ensure the appropriateness of the restraint use and to reassess the child's condition. However, the immediate priority is to monitor the child's vital signs closely to ensure their safety while restrained.
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Related Questions
Correct Answer is D
Explanation
Choice A Reason:
Exploitative behavior is more commonly associated with narcissistic personality disorder rather than obsessive-compulsive personality disorder (OCPD). Individuals with narcissistic personality disorder often manipulate and exploit others to achieve their own goals and maintain their self-esteem. This behavior is not characteristic of OCPD, which is more focused on orderliness, perfectionism, and control.
Choice B Reason:
Lack of empathy is a hallmark of antisocial personality disorder and narcissistic personality disorder. Individuals with OCPD may have difficulty understanding others' emotions due to their rigid thinking and focus on rules, but they do not typically exhibit a complete lack of empathy. Their interactions are more characterized by a need for control and perfectionism rather than a disregard for others' feelings.
Choice C Reason:
Excessive clinging is a symptom more commonly associated with dependent personality disorder. Individuals with dependent personality disorder have an excessive need to be taken care of, leading to submissive and clinging behaviors. In contrast, those with OCPD are more focused on maintaining control and order in their environment and relationships, rather than exhibiting dependency.
Choice D Reason:
Preoccupation with details is a core feature of obsessive-compulsive personality disorder. Individuals with OCPD are excessively focused on rules, schedules, and details to the extent that it interferes with their ability to complete tasks and maintain flexibility. This preoccupation often leads to inefficiency and difficulty in adapting to new situations, as they are overly concerned with perfectionism and control.
Correct Answer is A
Explanation
Choice A Reason:
Constant talking, also known as pressured speech, is a common symptom of mania in bipolar disorder. During a manic episode, individuals often experience a rapid flow of speech that is difficult to interrupt. This symptom is indicative of the heightened energy levels and racing thoughts associated with mania. Pressured speech can be overwhelming for both the individual and those around them, as it often includes rapid shifts in topics and an inability to focus on one subject.
Choice B Reason:
Expressing feelings of inferiority is more commonly associated with depressive episodes rather than manic episodes. During a depressive episode, individuals may experience low self-esteem, feelings of worthlessness, and a pervasive sense of sadness. These symptoms are in contrast to the elevated mood and increased self-confidence typically seen in mania.
Choice C Reason:
Memory loss is not a primary indicator of mania. While cognitive impairments can occur in bipolar disorder, they are not specific to manic episodes. Memory loss can be associated with various conditions, including depression, anxiety, and other neurological disorders. It is important to differentiate between symptoms specific to mania and those that may arise from other conditions.
Choice D Reason:
Sleeping over 10 hours a day is indicative of hypersomnia, which is more commonly seen in depressive episodes. During a manic episode, individuals typically experience a decreased need for sleep and may function on very little rest without feeling tired. The reduced need for sleep is a hallmark symptom of mania and helps distinguish it from depressive episodes.
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