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?
Have a staff member check on the client every 30 minutes.
Assess the client's need for toileting every 15 minutes.
Ask the provider to renew the prescription every 8 hours.
Offer hydration and nutrition to the client every 2 hours.
The Correct Answer is D
Choice A reason:
Having a staff member check on the client every 30 minutes is important for ensuring the client's safety and well-being. However, best practices suggest that continuous visual monitoring or checks at least every 15 minutes is generally recommended. This frequent monitoring allows for prompt identification and response to any distress or needs the client may have.
Choice B reason:
Assessing the client's need for toileting every 15 minutes may be excessive and could potentially cause additional distress or discomfort. The standard practice is to assess for toileting needs less frequently, typically every 2 hours, unless there is a specific indication that more frequent checks are necessary.
Choice C reason:
Asking the provider to renew the prescription for restraints every 8 hours is not aligned with standard guidelines. Restraint orders must be reviewed and renewed according to facility protocols, which usually require renewal every 24 hours. This ensures that the use of restraints is continually justified and that the client's condition is regularly reassessed.
Choice D reason:
Offering hydration and nutrition to the client every 2 hours is a critical aspect of care for a client in restraints. It is essential to meet the client's basic needs and to prevent dehydration and malnutrition. Additionally, providing hydration and nutrition at regular intervals aligns with the guidelines for monitoring and assessing clients in restraints.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
A client who is experiencing stimulant withdrawal may exhibit symptoms such as fatigue, depression, and increased appetite. While these symptoms can be distressing, they do not typically include seizures. Stimulant withdrawal does not usually necessitate seizure precautions because the risk of seizures is low.
Choice B reason:
A client who is experiencing opioid withdrawal may suffer from symptoms like anxiety, muscle aches, sweating, and nausea. Although opioid withdrawal can be very uncomfortable and distressing, it is not commonly associated with seizures. Therefore, seizure precautions are generally not required for opioid withdrawal.
Choice C reason:
A client who is experiencing cannabis withdrawal might experience irritability, sleep disturbances, and decreased appetite. Cannabis withdrawal is not typically associated with seizures, so seizure precautions are not necessary for these clients.
Choice D reason:
A client who is experiencing alcohol withdrawal is at a significant risk for seizures. Alcohol withdrawal can lead to severe complications such as delirium tremens, which includes symptoms like confusion, hallucinations, and seizures. Implementing seizure precautions for clients undergoing alcohol withdrawal is crucial to prevent injury and manage potential seizures effectively.
Correct Answer is D
Explanation
Choice A reason:
While being oriented to person, place, and time is important, it does not necessarily indicate that the client is no longer a risk to themselves or others. Orientation alone does not ensure that the client can safely be without restraints.
Choice B reason:
Refusing medication unless released from restraints is a form of coercion and does not indicate that the client is safe to be without restraints. The decision to remove restraints should be based on the client's ability to follow commands and demonstrate safe behavior, not on their demands.
Choice C reason:
If a client states that they will harm themselves unless the restraints are removed, this indicates a high risk of self-harm. In such cases, restraints should not be removed until the client is assessed and deemed safe by a healthcare professional.
Choice D reason:
The ability to follow commands is a key indicator that the client can be safely managed without restraints. This demonstrates that the client is cooperative and can adhere to safety instructions, reducing the risk of harm to themselves or others.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.