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 A

Explanation

A. Displacement involves redirecting emotions or behaviors from the original source to a less threatening or more accessible target. In this scenario, the client is redirecting his anger from his partner to the nurse, who is perceived as a safer target.
B. Compensation involves overachieving in one area to compensate for deficiencies in another area and is not demonstrated in this scenario.
C. Denial involves refusing to acknowledge the existence of a real situation or the feelings associated with it, which is not evident in the client's behavior.
D. Rationalization involves creating logical or socially acceptable explanations for behaviors or feelings that are unacceptable, which is not demonstrated in the client's behavior in this scenario.

A. "Why do you think that he said that to you?" B. "You sound upset about today's session." C. "I think you should ignore the comment." D. "I agree that the comment was inappropriate."

Correct Answer is B

Explanation

A. This response may inadvertently blame the client or imply that they provoked the inappropriate comment, which can be invalidating.
B. Validating the client's feelings acknowledges their experience and provides support.
C. Encouraging the client to ignore the comment may minimize their feelings and the impact of the inappropriate behavior.
D. Agreeing that the comment was inappropriate is validating, but it does not address the client's emotional response or provide support.

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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 A

Explanation

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Correct Answer is B

Explanation

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