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.

Answer and Explanation

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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Correct Answer is B

Explanation

A. Confidentiality rights are typically discussed during the orientation phase of the therapeutic relationship, not the working phase.
B. The working phase involves collaboration between the nurse and client to achieve goals. Evaluating progress is a key aspect of this phase.
C. Establishing boundaries is a task typically accomplished during the orientation phase, when the nurse and client are first getting to know each other.
D. Setting objectives is part of the initial phase of establishing the relationship and developing a treatment plan, not the working phase where action takes place.

A. "Everyone gets depressed from time to time." B. "You shouldn't worry about this, because depressive disorder is easily treated." C. "Older adults are usually diagnosed with depressive disorder as they age." D. "Tell me the reasons you think your mother is depressed."

Correct Answer is D

Explanation

A. While depression can occur in any age group, this response minimizes the client's feelings and may dismiss her concerns.
B. Depressive disorder is not always easy to treat and varies from person to person. It’s important to
acknowledge the seriousness of the concern.
C. Although depression can occur in older adults, this statement is overly general and dismisses the need for a thorough assessment to confirm a diagnosis.
D. Asking open-ended questions allows the daughter to express her observations, which helps the nurse gather more information and provide an appropriate response or intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is beginning a therapeutic relationship with a client. The nurse should plan to accomplish which of the following tasks during the working phase?

Correct Answer is B

Explanation

An older adult client is brought to the mental health clinic by her daughter. The daughter reports that her mother is not eating and seems uninterested in routine activities. The daughter states, "I'm so worried that my mother is depressed." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

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