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 A

Explanation

The correct answer is: A. Withhold the next dose of the medication.

Choice A rationale: Lamotrigine can cause serious skin reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis. Any rash should be taken seriously, and the medication should be withheld immediately to prevent potential severe reactions1.

Choice B rationale: While a change in laundry detergent could cause a rash, it is less likely to be the cause if the rash appeared after starting lamotrigine.

Choice C rationale: Applying hydrocortisone cream may help with mild skin irritations, but it does not address the potential severity of a drug-induced rash.

Choice D rationale: Explaining that the medication causes a temporary rash is not appropriate without first assessing the severity of the rash and withholding the medication.

A. Implement continuous one-to-one observation. B. Ask the client to sign a no-suicide contract. C. Encourage the client to participate in group therapy. D. Establish a rapport to foster trust.

Correct Answer is D

Explanation

The most important action for the nurse to take first is to establish a rapport and foster trust with the client. This is represented by option d.

Here's why the other options are not the best first steps:

a. Implement continuous one-to-one observation:While monitoring safety is crucial,it does not address the immediate emotional need of the client,who has just endured a traumatic experience.Building trust first can facilitate open communication and help the client feel safe enough to express their feelings and needs.
b. Ask the client to sign a no-suicide contract:No-suicide contracts have limited effectiveness and can even be harmful by putting undue pressure on the client.Building trust and a collaborative plan are more effective ways to manage safety.
c. Encourage the client to participate in group therapy:Group therapy can be beneficial,but it's not appropriate as the immediate first step.Individualized attention and establishing a secure relationship are crucial at this early stage.

Therefore, establishing rapport and fostering trust is the most important action for the nurse to take first. This will create a safe space for the client to openly express their thoughts and feelings, allowing the nurse to assess their needs and develop a proper care plan.

Remember, this is just the first step. Subsequent actions will involve a comprehensive assessment, safety measures, and collaborating with the client and other healthcare professionals to develop a personalized treatment plan.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who receives lamotrigine daily for bipolar disorder and reports a rash on his arm. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is caring for a client who is admitted to a mental health facility after attempting suicide. Which of the following actions should the nurse take first?

Correct Answer is D

Explanation

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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?