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?

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

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

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

Evaluate the client hourly while the restraints are applied.

Answer and Explanation

The Correct Answer is B

A. Obtain a prescription for restraints on an as-needed basis:
Restraints should never be used on an as-needed basis without a specific, individualized order from a healthcare provider. Restraints are a significant intervention that should only be used when necessary, and they require a clear prescription outlining the duration, reason, and method of application.

B. Have the provider assess the client within 1 hour after applying the restraints:
This option is the correct choice. It is crucial to involve the healthcare provider promptly after restraints are applied. The provider needs to assess the patient's physical and mental status, and the appropriateness of the restraints, and consider alternatives or modifications to the intervention. Regular assessments ensure the patient's safety and well-being while addressing the initial reason for applying restraints.

C. Request that the provider renew the prescription for restraints every 8 hours:
Restraining a patient every 8 hours without ongoing assessment and a clear clinical rationale is inappropriate and goes against best practices. Restraints should only be used when absolutely necessary and should be reevaluated frequently. Requesting a renewal on a fixed schedule without considering the patient's changing condition is not a safe or ethical approach.

D. Evaluate the client hourly while the restraints are applied:
While regular monitoring of a patient in restraints is essential, evaluating the patient every hour might not be sufficient, especially in the early stages after the application of restraints. The patient should be continuously monitored, with assessments conducted more frequently, especially immediately after applying the restraints, to ensure their safety and well-being.

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Correct Answer is C

Explanation

A. "I will do my best to avoid crying in front of my loved ones."
This statement suggests the client might be trying to hide their emotions, which can lead to further emotional distress. Suppressing emotions, like crying, is not a healthy coping mechanism and can exacerbate feelings of sadness and isolation.

B. “I will stay in bed on days when I feel exhausted."
Staying in bed excessively, especially during the day, is a behavior associated with depression and can worsen depressive symptoms. Encouraging the client to maintain a regular sleep schedule and engage in activities, even if they are small, is a more beneficial approach. Physical activity and exposure to natural light can positively impact mood.

C. “I’ll use the coping mechanisms that helped me in the past."
This is the correct choice. Reverting to previously effective coping mechanisms indicates an understanding of self-awareness and the ability to recognize what has worked positively in the past. Coping mechanisms such as relaxation techniques, hobbies, social support, or therapy can be valuable tools in managing depressive symptoms.

D. “I will avoid talking about events that upset me."
Avoiding discussions about upsetting events can prevent the client from addressing and processing their emotions, hindering the therapeutic process. Encouraging open communication and expressing feelings with a trusted individual, therapist, or support group can help the client work through emotional challenges.

A. "Did you experience any childhood trauma?" B. "Are you the result of a twin birth?" C. "Have you ever purposefully lost a job?" D. "Did your parent have a viral infection while pregnant with you?"

Correct Answer is C

Explanation

A. "Did you experience any childhood trauma?"
Childhood trauma, such as abuse or neglect, can contribute to various mental health conditions, including post-traumatic stress disorder (PTSD), depression, or anxiety disorders. While trauma can impact a person's mental health, it does not directly assess the risk for alcohol use disorder.

B. "Are you the result of a twin birth?"
Being a twin or the result of multiple births does not inherently indicate a risk for alcohol use disorder. This question is related to an individual's birth status and has no direct connection to the assessment of alcohol-related issues.

C. "Have you ever purposefully lost a job?"
This is the correct choice. Purposefully losing a job might indicate behavioral issues related to alcohol misuse or impairment. Individuals with alcohol use disorder may engage in behaviors that lead to job loss, such as absenteeism, poor performance, or conflict at the workplace due to alcohol consumption.

D. "Did your parent have a viral infection while pregnant with you?"
Prenatal viral infections can potentially affect fetal development and lead to certain health conditions. However, this question is not directly related to the risk of alcohol use disorder. Alcohol use disorder is primarily influenced by environmental factors, genetic predisposition, and individual behaviors related to alcohol consumption. Prenatal viral infections are not a typical indicator of alcohol-related concerns.

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