A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?

An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom.

An assistive personnel applies physical restraints on a client who is aggressive

An assistive personnel tells the provider that a client is making other clients feel unsafe.

An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm.

Answer and Explanation

The Correct Answer is B

A. An assistive personnel reapplies a soft limb restraint on a client after assisting them to the bathroom: Reapplying a soft limb restraint in itself does not necessarily require an incident report. However, the application must follow proper protocols, and the nurse should ensure that the assistive personnel are trained and following the correct procedures.
B. An assistive personnel applies physical restraints on a client who is aggressive: Physical restraints should only be applied with a physician's order and in accordance with facility policies. If restraints are applied without proper authorization or protocol, an incident report must be completed.
C. An assistive personnel tells the provider that a client is making other clients feel unsafe: Reporting concerns to the provider about a client's behavior is part of proper communication and does not require an incident report.
D. An assistive personnel provides 1:1 monitoring for a client who is reporting thoughts of self-harm: This is an appropriate and necessary intervention for a client at risk of self-harm. It does not require an incident report, as the staff member is performing their duty to ensure the safety of the client.

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Free Nursing Study Resources

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

Explanation

A. Request that security guards restrain the client: This should be a last resort. Restraints can escalate a situation and should only be used when necessary for safety. The nurse should attempt to de-escalate the situation first before involving security.

B. Speak to the client in a loud voice: Speaking loudly can escalate the situation, especially with someone who is already agitated. A calm, composed tone is more effective in de-escalating anxiety and aggression.

C. Stand directly in front of the client: Standing directly in front of the client can be perceived as confrontational and could increase the client's aggression. It's better to maintain a safe distance and stand at an angle, not directly in front of them.

D. Talk to the client using short, simple sentences: This is an appropriate response. When a client is agitated, they may have difficulty processing complex information. Using short, clear sentences can help them better understand and respond.

E. Identify the client's stressors: Understanding the client’s stressors helps the nurse address the root cause of the agitation and provides an opportunity to offer support or alternative coping strategies.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

Rationale:

Heart rate: The client's heart rate has increased to 124 beats per minute, which is significantly higher than normal. This tachycardia could be a sign of neuroleptic malignant syndrome (NMS), a potentially life-threatening reaction to antipsychotic medications like haloperidol.
Temperature: The client's elevated temperature of 39.5°C (103.1°F) is concerning and could be indicative of NMS, which often presents with hyperthermia as one of its hallmark symptoms. NMS is a medical emergency that requires immediate attention.

Rationale for incorrect choices:

Vision report: The client's report of blurry vision may be a side effect of haloperidol, but it is not typically considered a life-threatening reaction. It should be monitored but does not indicate an immediate crisis.
Blood pressure: While the blood pressure is slightly low, it is not as critical as the combination of elevated heart rate and temperature. The low blood pressure would require monitoring but is not immediately indicative of a life-threatening reaction.
Mouth report: Dry mouth is a common side effect of many medications, including antipsychotics like haloperidol. While uncomfortable, it is not a life-threatening condition.
Respiratory rate: The respiratory rate of 22/min is within normal limits and does not indicate any immediate concerns related to the medication. It should be monitored but does not raise a red flag for a life-threatening reaction.

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A nurse is supervising a group of staff members on a mental health unit. Which of the following actions require the nurse to complete an incident report?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who begins yelling and pacing around the room. Which of the following actions should the nurse take? (Select all that apply).

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

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}

Explanation

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