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.

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Correct Answer is D

Explanation

A. Asking a family member to check the locks for the client may alleviate immediate anxiety but does not address the underlying obsessive-compulsive behavior or provide coping mechanisms for the client to manage their symptoms independently.
B. Keeping a journal of checking behaviors may be part of exposure and response prevention therapy but does not directly address the intrusive thoughts associated with obsessive- compulsive disorder in the moment.
C. Focusing on abdominal breathing is a relaxation technique that may help reduce overall anxiety but does not specifically target the intrusive thoughts associated with obsessive- compulsive disorder.
D. Using a rubber band to snap on the wrist when the client thinks about checking the locks is a form of aversion therapy, which is a component of thought stopping technique. This technique helps interrupt and redirect the obsessive thoughts, promoting awareness and control over compulsive behaviors.

A. "How has this impacted your life?" B. "Are you okay with not being able to do some things you used to do?" C. "Is anyone available to assist you with your hygiene?" D. “Why do you think this has happened?"

Correct Answer is A

Explanation

A. This question assesses the client's perception of the impact of the stroke on their life, providing insight into their coping abilities and emotional response.

B. This question addresses acceptance but may not fully assess the client's coping strategies or emotional response to the stroke.
C. This question addresses practical assistance with hygiene tasks but does not directly assess coping mechanisms.
D. This question focuses on the cause of the stroke rather than the client's coping abilities or emotional response.

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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

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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