A nurse is discussing restraints with a newly licensed nurse. Which of the following situations should the nurse identify as an acceptable indication for using restraints for a client?
Inadequate staffing ratio between clients and health care providers
Discipline for throwing chairs at staff
Continued self-destructive behavior
Refusal to take medication
The Correct Answer is C
A. Inadequate staffing ratio between clients and health care providers:
This is never a justifiable reason for restraint use; it violates patient rights and ethical standards.
B. Discipline for throwing chairs at staff:
Restraints should never be used as punishment; they are only used to prevent harm after less restrictive measures have failed.
C. Continued self-destructive behavior:
Restraints may be used when a patient poses a risk to self or others, and all less restrictive interventions have been ineffective.
D. Refusal to take medication:
Refusal alone is not justification for restraint unless refusal leads to immediate danger and court-ordered treatment applies.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inadequate staffing ratio between clients and health care providers:
This is never a justifiable reason for restraint use; it violates patient rights and ethical standards.
B. Discipline for throwing chairs at staff:
Restraints should never be used as punishment; they are only used to prevent harm after less restrictive measures have failed.
C. Continued self-destructive behavior:
Restraints may be used when a patient poses a risk to self or others, and all less restrictive interventions have been ineffective.
D. Refusal to take medication:
Refusal alone is not justification for restraint unless refusal leads to immediate danger and court-ordered treatment applies.
Correct Answer is ["A","D","E"]
Explanation
A. Paranoid delusions:
Delirium tremens (DTs) may cause paranoid or persecutory delusions.
B. Grandiosity:
Typically associated with mania or certain personality disorders, not alcohol withdrawal.
C. Hypotension:
Alcohol withdrawal delirium is more likely to cause hypertension and tachycardia due to autonomic hyperactivity.
D. Tremors:
Tremors are a hallmark early sign of alcohol withdrawal and can persist into withdrawal delirium.
E. Visual hallucinations:
Alcohol withdrawal delirium often includes vivid visual (and tactile) hallucinations.
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