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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D"]
Explanation
Choice A reason:
The statement "Speak to the client in a loud voice" is not appropriate. Speaking loudly can escalate the client's agitation and increase their distress. It is important to use a calm, gentle tone to help de-escalate the situation.
Choice B reason:
The statement "Identify the client's stressors" is the correct response. Understanding what is causing the client's agitation can help in addressing the root cause and calming the client. Identifying stressors is a key step in managing agitation effectively.
Choice C reason:
The statement "Stand directly in front of the client" is not advisable. Standing directly in front of an agitated client can be perceived as confrontational and may increase their agitation. It is better to stand at an angle or to the side to avoid appearing threatening.
Choice D reason:
The statement "Talk to the client using short, simple sentences" is the correct response. Using clear, concise language helps the client understand instructions and reduces confusion, which can help in calming them down.
Choice E reason:
The statement "Request that security guards restrain the client" is not appropriate as a first response. Restraints should only be used as a last resort when the client poses an immediate danger to themselves or others and when less restrictive measures have failed.
Correct Answer is ["1.4"]
No explanation
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today