A nurse is caring for an adult client who has been placed in physical restraints due to aggressive behavior. Which of the following actions should the nurse take?
Assess the client's need for toileting every 15 min.
Ask the provider to renew the prescription every 8 hr.
Have a staff member check on the client every 30 min.
Offer hydration and nutrition to the client every 2 hr.
The Correct Answer is A
A. The nurse should assess the client’s need for toileting regularly, as restricted movement can increase the risk of discomfort and physical harm. Monitoring this every 15 minutes is recommended for ensuring the client's basic needs are met.
B. Physical restraint prescriptions should be renewed at intervals that are consistent with the facility’s
policies, but every 8 hours is typically too long. A more frequent reassessment should occur.
C. Clients in restraints should be monitored more frequently than every 30 minutes to ensure their safety and well-being, especially in terms of physical comfort and circulation.
D. Offering hydration and nutrition every 2 hours may not be necessary if the client is receiving fluids and food regularly, but they should be monitored more frequently for other immediate needs.
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Related Questions
Correct Answer is A
Explanation
A. The nurse should assess the client’s need for toileting regularly, as restricted movement can increase the risk of discomfort and physical harm. Monitoring this every 15 minutes is recommended for ensuring the client's basic needs are met.
B. Physical restraint prescriptions should be renewed at intervals that are consistent with the facility’s
policies, but every 8 hours is typically too long. A more frequent reassessment should occur.
C. Clients in restraints should be monitored more frequently than every 30 minutes to ensure their safety and well-being, especially in terms of physical comfort and circulation.
D. Offering hydration and nutrition every 2 hours may not be necessary if the client is receiving fluids and food regularly, but they should be monitored more frequently for other immediate needs.
Correct Answer is C
Explanation
A. While this question may provide some insight into the client's feelings, it is more focused on acceptance and may not fully assess their coping mechanisms.
B This is a practical question addressing the client's needs but does not directly assess the client's coping ability.
C. Asking about the impact of the stroke on the client's life helps assess their emotional response and coping mechanisms. It provides the nurse with a broader understanding of how the client is adjusting to their condition.
D. This question may put the client on the defensive or lead to feelings of guilt or frustration, which may hinder their coping process. The focus should be on understanding the client's emotional response rather than exploring blame.
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