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 A

Explanation

The nurse's priority is to address the client's physical needs, such as nutrition and hydration, which are essential for survival and recovery. The client who is unable to eat more than once a day is at risk for malnutrition, dehydration, and electrolyte imbalance, which can lead to serious complications. The other findings indicate emotional distress and grief, which are also important to address, but not as urgent as the client's physical health.

A. Weigh the client weekly for the first month. B. Negotiate with the client how much weight she should gain each week. C. Notify the client about designated times for meals. D. Decrease the client's daily intake of fiber.

Correct Answer is B

Explanation

The nurse should collaborate with the client to set realistic and achievable goals for weight gain and recovery. This can help increase the client's sense of control and motivation. The other options are not appropriate because they do not involve the client in the decision-making process, and they may increase the client's resistance or anxiety.

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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

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