A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?

Monitor the child's vital signs every 15 min.

Have the child perform range-of-motion exercises every 3 hr.

Ensure three fingers will fit between the child's wrist and the restraint.

Obtain a prescription for the restraints within 2 hr of initiating them.

Answer and Explanation

The Correct Answer is D

The nurse should obtain a prescription for the restraints within 2 hr of initiating them, as this is a legal requirement and ensures that the restraints are used appropriately and safely. The other options are also important, but they are not the priority action in this situation.

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Correct Answer is B

Explanation

Phenelzine is a monoamine oxidase inhibitor (MAOI) that can cause a hypertensive crisis if taken with foods that contain tyramine, such as pepperoni pizza. The nurse should assess the client's blood pressure to monitor for signs of hypertension, such as headache, chest pain, or blurred vision.

A. Flight of ideas B. Decreased motivation C. Impaired memory D. Delusions of grandeur E. Auditory hallucinations

Correct Answer is ["A","D","E"]

Explanation

Positive symptoms of schizophrenia are those that add something to the normal experience, such as hallucinations, delusions, disorganized speech, and abnormal motor behavior. Flight of ideas is a type of disorganized speech that involves rapid switching from one topic to another. Delusions of grandeur are false beliefs of having superior power or status. Auditory hallucinations are hearing voices or sounds that are not real. Negative symptoms of schizophrenia are those that take something away from the normal experience, such as decreased motivation, impaired memory, flat affect, and social withdrawal.

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A nurse is caring for a school-age child who has conduct disorder and requires wrist restraints. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has depression and takes phenelzine. The client reports eating pepperoni pizza while out on a pass during lunchtime. Which of the following assessments should the nurse perform?

Correct Answer is B

Explanation

A nurse is assessing a client who has schizophrenia. Which of the following findings should the nurse document as positive symptoms of schizophrenia? (Select all that apply.)

Correct Answer is ["A","D","E"]

Explanation

A nurse is assessing a client who recently experienced the loss of their partner. Which of the following questions is the priority for the nurse to ask during this situational crisis?

A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client. Which of the following actions should the nurse take?

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