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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
The statement "You should take a 2-hour nap during the afternoon" is not advisable. While short naps can be beneficial, long naps, especially those taken late in the day, can interfere with nighttime sleep by reducing sleep drive. It is generally recommended to limit naps to 20-30 minutes and to avoid napping late in the afternoon.
Choice B reason:
The statement "You should relax by watching a television show in bed before going to sleep" is not recommended. Watching television or using other electronic devices before bed can negatively impact sleep quality. The blue light emitted from screens can suppress melatonin production, making it harder to fall asleep. It is better to engage in relaxing activities that do not involve screens, such as reading a book or listening to calming music.
Choice C reason:
The statement "You should avoid stressful activities prior to going to sleep" is the correct response. Engaging in stressful activities before bed can increase anxiety and make it difficult to fall asleep. It is important to establish a relaxing bedtime routine that includes activities such as deep breathing exercises, meditation, or gentle stretching to promote better sleep.
Choice D reason:
The statement "You should plan to exercise 2 hours before going to sleep" is partially correct but not ideal. While regular exercise can improve sleep quality, exercising too close to bedtime can have the opposite effect for some people. It is generally recommended to finish exercising at least 3-4 hours before bedtime to allow the body to wind down.
Correct Answer is D
Explanation
Choice A reason:
The statement "Improving cognitive status with transcranial magnetic stimulation" is not typically included in the standard treatment options for Alzheimer's disease. While transcranial magnetic stimulation (TMS) is being researched for various neurological conditions, its efficacy in treating Alzheimer's disease is not well-established. Current treatments focus more on medications that can help manage symptoms and slow disease progression.
Choice B reason:
The statement "Controlling anxiety with barbiturate medications" is not recommended. Barbiturates are generally avoided in elderly patients, including those with Alzheimer's disease, due to their high risk of side effects and potential for dependence. Instead, other medications such as antidepressants or antipsychotics may be used to manage anxiety and other psychiatric symptoms associated with Alzheimer's.
Choice C reason:
The statement "Initiating hospice care services when the client has 6 months or less to live" is important but not relevant to the initial teaching for a newly diagnosed client. Hospice care is considered when the disease has progressed to a terminal stage, and the focus shifts to palliative care. Early-stage treatment focuses on managing symptoms and maintaining quality of life.
Choice D reason:
The statement "Delaying cognitive impairment with NMDA receptor agonist medications" is the correct response. NMDA receptor antagonists, such as memantine, are used to treat moderate to severe Alzheimer's disease. These medications help regulate glutamate activity in the brain, which can improve cognitive function and slow the progression of symptoms.
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