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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason:
When leading a crisis intervention group, especially for adolescents who have witnessed the traumatic event of a classmate's suicide, it is crucial to first identify the individuals' prior coping skills. This initial step is essential because it helps the nurse to understand the baseline coping mechanisms each adolescent has previously employed. Adolescents may have varying levels of resilience and different strategies for dealing with stress and trauma. By identifying these skills early on, the nurse can tailor the intervention to reinforce these existing skills while introducing new coping strategies. This personalized approach ensures that each adolescent's unique needs are addressed, which is particularly important in the aftermath of a suicide, where feelings of guilt, confusion, and grief can be overwhelming. Moreover, understanding their prior coping skills can help the nurse to predict potential challenges and provide targeted support to those who may be more vulnerable or at risk of negative outcomes.

Choice B reason:
Reviewing community resources is an important action but not the first one that should be taken. Community resources can provide additional support and services to the adolescents after the initial crisis intervention. These resources might include mental health services, support groups, or educational programs. However, before directing adolescents to these resources, it is essential to assess their current psychological state and coping abilities. This ensures that the resources recommended are appropriate and beneficial for each individual's specific situation.

Choice C reason:
Discussing the importance of confidentiality is a critical component of any therapeutic intervention, particularly in a group setting. It creates a safe space where adolescents feel secure to share their thoughts and feelings without fear of judgment or breach of privacy. However, this is not the first action to take. Establishing confidentiality is part of setting the ground rules for the group intervention, which typically occurs after initial assessments and once a rapport has been established.

Choice D reason:
Initiating referrals may be necessary for adolescents who require more specialized care or individual therapy. Referrals are an important part of the continuum of care and ensure that adolescents have access to the appropriate level of support. However, this action is typically taken after the initial crisis intervention session, where the nurse has had the opportunity to assess each adolescent's needs and determine who might benefit from additional services.

A. Holds persistent negative beliefs about self B. Talks excessively C. Blames others for own mistakes D. Difficulty falling or staying asleep E. Has difficulty concentrating on set tasks

Correct Answer is ["A","D","E"]

Explanation

Choice A reason:
Clients with PTSD often hold persistent negative beliefs about themselves, which is a core symptom of the condition. These beliefs may include thoughts of being bad, unworthy, or responsible for the traumatic event. This negative self-perception can contribute to feelings of shame, guilt, and low self-esteem, which are common among individuals with PTSD.

Choice B reason:
Talking excessively is not typically associated with PTSD. While some individuals may talk more when they are anxious or trying to avoid certain thoughts, it is not a diagnostic criterion or a common finding in PTSD. Instead, individuals with PTSD may avoid talking about the traumatic event and may be withdrawn or socially isolated.

Choice C reason:
Blaming others for one's own mistakes is not a characteristic finding in PTSD. Individuals with PTSD may experience heightened irritability or anger, but this symptom does not specifically include blaming others for personal mistakes. It is more common for individuals with PTSD to have distorted perceptions of blame related to the traumatic event, often blaming themselves when it is not warranted.

Choice D reason:
Difficulty falling or staying asleep is a common symptom of PTSD. Sleep disturbances, including insomnia, nightmares, and restless sleep, are frequently reported by individuals with PTSD. These issues can be directly related to hyperarousal and intrusive thoughts or memories of the traumatic event.

Choice E reason:
Having difficulty concentrating on tasks is another symptom commonly seen in individuals with PTSD. This difficulty can be due to intrusive thoughts, hyperarousal, or general distress related to the traumatic event. It can affect various aspects of daily life, including work, school, and social interactions.

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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 leading a crisis intervention group for adolescents who witnessed the suicide of a classmate. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is assessing a client who has post-traumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply)

Correct Answer is ["A","D","E"]

Explanation

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