A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client.
Which of the following actions should the nurse take?

Request that the provider renew the prescription for restraints every 8 hr.

Have the provider assess the client within 1 hr after applying the restraints.

Evaluate the client hourly while the restraints are applied.

Obtain a prescription for restraints on an as-needed basis.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Requesting that the provider renew the prescription for restraints every 8 hours is not the best approach. The nurse should follow the facility's policies and protocols for the use of restraints, and these policies typically require that the provider assess the client within a specific timeframe after applying restraints. The provider's assessment should occur promptly to determine the client's continued need for restraints and to address the client's safety and well-being.

Choice C rationale:

Evaluating the client hourly while the restraints are applied is not sufficient. While it's important to monitor the client, especially in terms of circulation and comfort, the provider's assessment should take place within a shorter timeframe, typically within one hour after applying the restraints. Hourly evaluations alone may not be timely enough to address the client's condition and the necessity of the restraints.

Choice D rationale:

Obtaining a prescription for restraints on an as-needed basis is not an appropriate approach. Restraints should only be used when necessary to ensure the safety of the client or others, and their use should be based on a specific assessment by the provider. Using restraints on an as-needed basis without a clear prescription can lead to ethical and legal issues and should be avoided.

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Correct Answer is C

Explanation

Choice A rationale:

Hypertension, while a medical condition, is not a direct risk factor for delirium. Delirium is typically associated with factors such as infection, medication side effects, metabolic imbalances, or acute changes in medical conditions, rather than chronic conditions like hypertension.

Choice B rationale:

Neuropathy is also not a direct risk factor for delirium. Delirium is more commonly associated with acute changes in neurological status or conditions that affect brain function.

Choice C rationale:

A white blood cell (WBC) count of 13,000/mm³ is an elevated count and may indicate an underlying infection or inflammation. Infection and inflammation are common causes of delirium, making an elevated WBC count a potential risk factor for developing delirium.

Choice D rationale:

A blood urea nitrogen (BUN) level of 16 mg/dL is slightly elevated but is not a direct risk factor for delirium. Delirium is more often associated with metabolic imbalances, electrolyte abnormalities, or acute changes in kidney function. A BUN level of 16 mg/dL alone is not a major contributor to delirium. .

A. Explain implied consent to the client's family. B. Contact the facility social worker to obtain the consent. C. Request that the client's guardian sign the consent. D. Ask the charge nurse to obtain informed consent.

Correct Answer is C

Explanation

Choice A rationale:

Explaining implied consent to the client's family is not the appropriate action in this situation. Implied consent typically refers to situations where consent is assumed due to the client's actions or circumstances, but it is not applicable when a client has been declared legally incompetent. The nurse should seek consent from a legally authorized representative, such as a guardian, in this case.

Choice B rationale:

Contacting the facility social worker is a good step to take when dealing with complex legal and ethical situations. However, the nurse's primary responsibility is to ensure that the client's legally authorized representative provides informed consent. This means that the client's guardian should be the one to sign the consent form, rather than the social worker.

Choice D rationale:

Asking the charge nurse to obtain informed consent is not the appropriate action because obtaining consent is typically the responsibility of the healthcare provider or a legally authorized representative. The charge nurse may not have the legal authority to provide informed consent on behalf of the client.

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A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client.Which of the following actions should the nurse take?

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A nurse on a mental health unit placed a client in mechanical restraints after the client assaulted another client.
Which of the following actions should the nurse take?