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 B
Explanation
Choice A Reason:
Narcissistic personality disorder is characterized by a pervasive pattern of grandiosity, need for admiration, and lack of empathy. Clients with this disorder do not typically experience sensory impairments as a direct result of their condition. The primary concerns with narcissistic personality disorder involve interpersonal relationships and self-esteem issues rather than sensory deficits.
Choice B Reason:
Conversion disorder, also known as functional neurological symptom disorder, involves neurological symptoms that cannot be explained by medical or neurological conditions. These symptoms can include sensory impairments such as blindness, deafness, or loss of sensation. Assessing clients with conversion disorder for sensory impairments is crucial because these symptoms are a key feature of the disorder. The nurse should evaluate the client's sensory function to provide appropriate care and support.
Choice C Reason:
Mild anxiety disorder typically involves symptoms such as excessive worry, restlessness, and physical symptoms like increased heart rate or muscle tension. Sensory impairments are not a common feature of mild anxiety disorder. While anxiety can affect perception and concentration, it does not usually lead to sensory deficits. The nurse should focus on managing anxiety symptoms rather than assessing for sensory impairments.
Choice D Reason:
Severe obsessive-compulsive disorder (OCD) involves intrusive thoughts (obsessions) and repetitive behaviors (compulsions). While OCD can significantly impact a client's daily functioning and quality of life, it does not typically cause sensory impairments. The primary focus for clients with severe OCD should be on managing obsessions and compulsions through therapy and medication.
Correct Answer is A
Explanation
Choice A: Temperature
Reason: The client’s temperature is 39.4°C (103°F), which is significantly above the normal range of 36.5°C to 37.3°C (97.8°F to 99.1°F). This indicates a fever, which can be a sign of infection or other serious conditions that require immediate medical attention. In the context of a client taking antipsychotic medications like olanzapine, a high fever could also indicate neuroleptic malignant syndrome (NMS), a potentially life-threatening condition.
Choice B: Blood Pressure
Reason: The client’s blood pressure is 128/82 mmHg, which falls within the normal range of 90/60 mmHg to 120/80 mmHg. While slightly elevated, it is not critically high and does not require immediate reporting compared to the other findings.
Choice C: Weight Gain
Reason: The client reports a weight gain of 2.2 kg (4.9 lb) in the past week. While significant, weight gain is a common side effect of olanzapine. It is important to monitor, but it is not as urgent as the elevated temperature.
Choice D: Hallucinations
Reason: The client reports hearing voices, which is a symptom of schizophrenia. While this is important to manage, it is a known symptom of the client’s condition and is being treated with olanzapine. The immediate concern is the elevated temperature, which could indicate a more acute issue.
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