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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Related Questions
Correct Answer is B
Explanation
A. The client expresses feelings of guilt.
Feelings of guilt are a common part of the grieving process. Many people may experience guilt related to things they said or didn't say, things they did or didn't do before their loved one's death. While it can be challenging, it is not necessarily a maladaptive grief response.
B. The client is unable to perform basic hygiene tasks.
This indicates a maladaptive grief response. If the client's grief has led to such severe impairment in functioning that they cannot maintain basic hygiene, it suggests an inability to cope and function in daily life, which is concerning and requires intervention and support.
C. The client gives away some of the partner's belongings.
This behavior is a common part of the grieving process. It can represent the client's attempt to let go and move on. It might also be an expression of their partner's wishes or a way to help others in need. Giving away belongings is not inherently maladaptive; it depends on the context and the individual's overall coping abilities.
D. The client relocates from a house to an apartment.
Changes in living arrangements after the loss of a loved one are often part of adapting to the new circumstances. It can be a way for the individual to reduce their responsibilities, live in a more manageable space, or seek a fresh start. Relocating, on its own, is not a maladaptive response to grief.
Correct Answer is B
Explanation
A. Contact a close relative of the client to discuss the discharge plan:
Involving close relatives or a support system can be beneficial for the client's recovery. However, it's crucial to respect the client's confidentiality and privacy. In some cases, clients might not want their relatives involved or might not have a supportive family environment, so this option should be approached cautiously and with the client's consent.
B. Refer the client to a self-help group:
This is a highly recommended action. Self-help groups like Alcoholics Anonymous (AA) provide a supportive environment where individuals with alcohol use disorder can share their experiences and coping strategies. These groups can significantly contribute to maintaining sobriety after rehabilitation.
C. Request a discharge prescription for buprenorphine for the client:
Buprenorphine is typically used to treat opioid use disorder, not alcohol use disorder. Medications like disulfiram, naltrexone, and acamprosate are more commonly prescribed to help individuals manage alcohol cravings and maintain abstinence. However, the choice of medication should be individualized and determined by a healthcare provider based on the client's specific needs and medical history.
D. Teach the client to practice systematic desensitization:
Systematic desensitization is a therapeutic technique used to treat phobias and anxieties by gradually exposing individuals to their fears in a controlled and safe manner. While it can be helpful for addressing anxiety-related issues, it's not a standard treatment for alcohol use disorder. Therapeutic interventions for alcohol use disorder often focus on behavioral therapies, counseling, and support groups.
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