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 D

Explanation

Choice A rationale:

Hypothyroidism is not directly related to the use of bupropion for smoking cessation. It is essential to consider the client's overall health, but in this context, it is not the most significant concern, so it does not need to be reported immediately.

Choice B rationale:

Knee arthroplasty one month ago is not a contraindication for bupropion use, but it is essential to consider postoperative precautions and mobility. However, it is not the most critical issue related to the client's request for smoking cessation medication, so it does not need immediate reporting.

Choice C rationale:

Hepatitis B infection is a concern but does not necessarily contraindicate the use of bupropion. The nurse should address this issue, but it is not the most urgent concern for the client's request for smoking cessation medication.

Choice D rationale:

Reporting a recent head injury is crucial because bupropion is contraindicated in clients with a history of seizures or conditions that lower the seizure threshold, such as recent head trauma. Seizures are a significant potential side effect of bupropion, and a recent head injury could increase the risk of seizures. Therefore, the nurse should report this finding immediately to ensure the client's safety.

A. "Lots of people feel ashamed to tell their secrets.”. B. "You will feel better if you tell me what you did last night.”. C. "Let's discuss what you feel embarrassed about.”. D. "You shouldn't feel embarrassed to talk to me.”.

Correct Answer is C

Explanation

Choice A rationale:

The response, "Lots of people feel ashamed to tell their secrets," is not the most therapeutic option because it does not directly address the client's need to discuss their feelings or concerns. It does offer some empathy but falls short in terms of encouraging communication and understanding.

Choice B rationale:

The response, "You will feel better if you tell me what you did last night," may come across as too direct and pressuring, which can be counterproductive in building trust with the client. It may make the client feel even more embarrassed or uncomfortable.

Choice D rationale:

The response, "You shouldn't feel embarrassed to talk to me," attempts to reassure the client but may invalidate their feelings and is not as therapeutic as the correct choice. It's important to acknowledge the client's emotions and provide them with a safe space to open up.

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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 obtaining a medical history from a client who is requesting a prescription for bupropion for smoking cessation.Which of the following assessment findings in the client's history should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is caring for a client who states, "I am too embarrassed to tell anyone what I did last night.”. Which of the following responses should the nurse make?

Correct Answer is C

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?