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 C

Explanation

This question helps the nurse to evaluate the client's personal coping skills and identify their strengths and weaknesses. Asking about the impact of the situation, the current feelings, or the future outlook are not directly related to coping skills, although they might provide some useful information.

A. Lanugo covering the body B. +2 edema of the lower extremities C. BUN 21 mg/dL D. Blood pH 7.60

Correct Answer is D

Explanation

A blood pH of 7.60 indicates alkalosis, which is a life-threatening condition that can result from vomiting, laxative abuse, or diuretic use in clients who have anorexia nervosa. Alkalosis can cause cardiac arrhythmias, seizures, coma, and death if not corrected promptly. The nurse should notify the provider and prepare to administer IV fluids and electrolytes as ordered. The other findings are also concerning, but they are not as urgent as alkalosis.

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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 caring for a client who has depression following a recent job loss. Which of the following questions should the nurse ask to assess the client's personal coping skills?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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