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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A rationale:

Asking how the event is affecting the client's life is important, but it is not the priority during a situational crisis. Safety and assessing for self-harm thoughts come first.

Choice B rationale:

This question is the priority because it assesses the client's safety and potential for self-harm, which is crucial during a crisis. If the client is having thoughts of self-harm, immediate intervention is required.

Choice C rationale:

Inquiring about the client's coping strategies is relevant, but it is not the primary concern when there is a potential risk of self-harm.

Choice D rationale:

Asking about who the client talks to for help is important but not the primary concern in a situation where self-harm may be a risk.

A. Acetaminophen. B. Warfarin. C. Fluoxetine. D. Calcium carbonate.

Correct Answer is C

Explanation

Choice A rationale:

Acetaminophen is not contraindicated when taken with selegiline. There is no significant interaction between these two medications.

Choice B rationale:

Warfarin is not contraindicated when taken with selegiline. While selegiline may increase the risk of bleeding in combination with other drugs, warfarin itself is not directly contraindicated.

Choice C rationale:

Fluoxetine is contraindicated when taken with selegiline. When these two drugs are used together, there is an increased risk of serotonin syndrome, which can be a life-threatening condition. Serotonin syndrome can cause symptoms such as agitation, hallucinations, rapid heartbeat, fever, muscle stiffness, and tremors.

Choice D rationale:

Calcium carbonate is not contraindicated when taken with selegiline. These two medications do not have significant interactions.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 assessing a client who recently experienced the loss of their partner.Which of the following questions is the priority for the nurse to ask during this situational crisis?

Correct Answer is B

Explanation

A nurse is reviewing the medication administration record of a client who has major depressive disorder and a new prescription for selegiline.The nurse should recognize that which of the following client medications is contraindicated when taken with selegiline?

Correct Answer is C

Explanation

A nurse is caring for a client who has borderline personality disorder and has been engaging in self-mutilation.The nurse should encourage the client to participate in which of the following groups?

A nurse is reviewing the laboratory report of a client who has a panic disorder and is taking clonazepam.Which of the following laboratory results should the nurse report to the provider?

A nurse is planning care for a newly admitted client who has anorexia nervosa. Which of the following interventions should the nurse include in the plan?

A nurse is caring for a client who exhibits chronic physical symptoms that cannot be fully explained by medical conditions.These symptoms cause distress and impairment in the client's daily life.What term is used to describe this condition?

A client with OCD is undergoing cognitive-behavioral therapy (CBT). The client asks the nurse, "How does exposure and response prevention work in treating OCD?" Which response by the nurse accurately explains this aspect of CBT?

A nurse is preparing for an interprofessional team meeting regarding a newly admitted client who has major depressive disorder. Which of the following findings obtained during the initial assessment is the priority to report to other disciplines?

A nurse is receiving change-of-shift report for four clients.Which of the following clients should the nurse see first?

A nurse is caring for a client who has just received a terminal cancer diagnosis from his provider.Which of the following actions should the nurse take?

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?