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?

Ask the provider to renew the prescription every 8 hr.

Have a staff member check on the client every 30 min.

Assess the client's need for toileting every 15 min.

Offer hydration and nutrition to the client every 2 hr.

Answer and Explanation

The Correct Answer is D

A. The provider must renew the prescription for restraints every 4 hours for adults, not every 8 hours.
B. A staff member should check on the client every 15 minutes, not every 30 minutes, to ensure safety.
C. The client should be assessed for toileting needs every 2 hours, not every 15 minutes.
D. Offering hydration and nutrition every 2 hours is appropriate to maintain the client’s basic needs while in restraints.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Safety is paramount, and if a client expresses intent to harm someone, it must be taken seriously and reported to local authorities to prevent harm and ensure the safety of the potential victim.
B. Confidentiality is important, but when there is a threat to harm others, the duty to warn and protect overrides confidentiality.
C. While informing risk management may be appropriate in some situations, when there is an imminent threat of harm, immediate action is necessary, which includes reporting to local authorities.
D. Delaying discharge to work on anger management may not be sufficient to ensure the safety of the potential victim. Reporting the threat to local authorities is necessary to prevent harm.

A. "It must be frightening to think that someone is reading your mail." B. "You know that's not true, because it is against the law for others to read your mail." C. "All of your letters come sealed, so that seems unlikely." D. "Why do you think the government wants to read your mail?"

Correct Answer is A

Explanation

A. This response acknowledges the client's feelings and validates their experience without confirming or denying the delusion.
B. This response challenges the client's belief and may cause distress or exacerbate paranoia.

C. While factually correct, this response may not address the client's underlying concerns or feelings.
D. This response may invalidate the client's experience and may not effectively address the delusional belief.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 caring for a client who has antisocial personality disorder and reports planning to hurt their partner upon discharge. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client in an inpatient mental health facility. The client tells the nurse that the government is reading her mail. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is caring for a client who has right-sided hemiplegia following a recent stroke. Which of the following questions should the nurse ask to determine the client's ability to cope?

A nurse is providing teaching to the caregiver of an older adult client who has Alzheimer's disease and is being cared for at home. The client wanders at night and has a history of previous falls. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

A nurse in a mental health facility is admitting a client. Exhibits A nurse is caring for a client who was admitted for alcohol use disorder. Which of the following findings require follow-up by the nurse? Select all that apply.

A nurse is teaching a client who is to start taking fluoxetine. The nurse should instruct the client that which of the following supplements Interacts adversely with fluoxetine?

A nurse is caring for a client who is experiencing alcohol withdrawal. Exhibits A nurse is planning care for a client who has alcohol use disorder. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.

A nurse is conducting an admission interview with a client who is experiencing mania. Which of the following findings should the nurse report to the provider?

A nurse is caring for a client who reports that he is angry with his partner because she thinks he is just trying to gain attention. When the nurse attempts to talk to the client, he becomes angry and tells her to leave. Which of the following defense mechanisms is the client demonstrating?

A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider. Which of the following actions should the nurse take?