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 D
Explanation
Choice A reason:
The statement "These symptoms will improve over time" is not appropriate in this context. Lethargy, muscle weakness, and blurred vision are potential signs of lithium toxicity, which requires immediate attention. Lithium toxicity can occur when lithium levels in the blood become too high, and it is crucial to monitor these levels regularly to prevent serious side effects.
Choice B reason:
The statement "Continue the medication as prescribed" is also not appropriate. Continuing the medication without addressing the symptoms could lead to worsening of the client's condition. Lithium toxicity can cause severe health issues, and it is essential to assess the client's lithium levels to determine if an adjustment in dosage is necessary.
Choice C reason:
The statement "You should decrease your intake of sodium" is incorrect. Sodium intake can affect lithium levels in the blood, but it is not advisable to make sudden changes in sodium intake without medical supervision. A sudden decrease in sodium can lead to higher lithium levels, increasing the risk of toxicity.
Choice D reason:
The statement "You will need to have your blood drawn" is the correct response. Monitoring lithium levels through blood tests is essential to ensure they remain within the therapeutic range (0.6 to 1.2 mEq/L). Blood tests help detect any signs of lithium toxicity and allow for timely adjustments to the medication dosage.
Correct Answer is A
Explanation
Choice A Reason:
Using short, simple sentences is an effective communication strategy for clients experiencing moderate anxiety. Anxiety can impair cognitive processing, making it difficult for clients to understand complex information. By using clear and concise language, the nurse can help the client better comprehend what to expect after the cardiac catheterization. This approach reduces the client's anxiety by providing information in a manageable format.
Choice B Reason:
Showing a 30-minute teaching video might be overwhelming for a client with moderate anxiety. While visual aids can be helpful, the length and complexity of the video could increase the client's anxiety rather than alleviate it. It is important to tailor the educational approach to the client's current emotional state, ensuring that the information is presented in a way that is easy to understand and not overwhelming.
Choice C Reason:
Providing detailed explanations can be counterproductive for a client with moderate anxiety. Detailed information might overwhelm the client, leading to increased anxiety and difficulty in processing the information. Instead, the nurse should focus on delivering key points in a clear and concise manner, ensuring that the client understands the most important aspects of the procedure and what to expect afterward.
Choice D Reason:
Avoiding questions is not an effective strategy for client education. Asking questions allows the nurse to assess the client's understanding and address any concerns or misconceptions. Engaging the client in a dialogue helps to build rapport and ensures that the client feels supported and informed. It is important to create an open and interactive environment where the client feels comfortable asking questions and expressing concerns.
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