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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. "My partner and I recently had our fourth child."
Having a strong support system, such as a partner and family, especially during significant life events like the birth of a child, can be a protective factor against suicide. Supportive relationships are important for mental well-being.
B. "My family has a history of suicide."
A family history of suicide is a risk factor, not a protective factor. It indicates a higher risk for suicidal thoughts or behaviors.
C. “I have Crohn's disease, but it's well-controlled."
Having a chronic illness, even if well-controlled, can be a stressor, potentially increasing the risk of suicidal thoughts. It's not a protective factor.
D. “I just received my license to practice medicine."
Achieving a significant milestone, such as getting a medical license, can enhance self-esteem, provide a sense of purpose, and increase social support, making it a protective factor against suicide.
Correct Answer is C
Explanation
A. Prepare the client for electroconvulsive therapy:
Electroconvulsive therapy (ECT) is not a standard or appropriate treatment for anorexia nervosa. ECT is primarily used for severe depression, bipolar disorder, and certain other mental health conditions. Anorexia nervosa is typically managed through psychotherapy, nutritional counseling, and medical monitoring, often in an outpatient or inpatient setting, depending on the severity of the disorder.
B. Weigh the client twice per day:
Frequent weighing is generally discouraged in the treatment of anorexia nervosa. Individuals with this disorder often have an unhealthy fixation on their weight. Frequent weigh-ins can exacerbate anxiety, foster an unhealthy relationship with food and body image, and reinforce obsessive thoughts about weight and appearance. Healthcare providers should monitor weight and nutritional status regularly, but the frequency should be determined based on the individual's specific needs and in a manner that does not worsen their anxiety.
C. Encourage the client to participate in family therapy:
This is the appropriate choice. Family therapy is often a crucial component of the treatment plan for anorexia nervosa. It helps address family dynamics, communication patterns, and any dysfunctional relationships that might contribute to the eating disorder. Family therapy provides a supportive environment for both the individual with anorexia and their family members, aiding in understanding, coping, and healing.
D. Set a weight gain goal of 2.2 kg (4.9 lb) per week:
Setting specific weight gain goals can be counterproductive and potentially harmful for individuals with anorexia nervosa. Rapid or arbitrary weight gain goals may lead to unhealthy eating behaviors, excessive exercise, or other dangerous practices in an attempt to meet the goal quickly. Instead, healthcare providers focus on a more individualized and gradual approach to weight restoration, ensuring that it is safe, sustainable, and in line with the client's overall health and well-being.
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