A patient becomes agitated and physically aggressive on the unit, requiring the use of restraints. Which of the following actions by the nurse is appropriate when applying and managing restraints?

Apply restraints and leave the patient unattended for 2 hours

Restrain the patient to the bed using all four limbs tightly to limit any movement

Ensure a provider’s face-to-face evaluation occurs within 1 hour of restraint application

Document the restraint use once at the end of the shift

Answer and Explanation

The Correct Answer is C

Choice A reason: Leaving a restrained patient unattended for 2 hours violates safety standards, as restraints pose risks like injury or respiratory compromise. Regular monitoring is required to assess circulation, skin integrity, and psychological distress, ensuring patient safety, making this choice incorrect.

Choice B reason: Restraining all four limbs tightly risks injury, such as nerve damage or impaired circulation, and violates least-restrictive restraint principles. Restraints should allow minimal movement and be applied only as necessary, with regular reassessment, making this choice incorrect.

Choice C reason: A provider’s face-to-face evaluation within 1 hour is required by regulations to ensure restraints are justified and safe. This assesses the patient’s condition, mental status, and need for continued restraint, minimizing harm and ensuring compliance, making this the correct choice.

Choice D reason: Documenting restraint use only at shift’s end is inadequate, as regulations require ongoing documentation of restraint rationale, patient condition, and monitoring. Delayed documentation risks missing critical changes, compromising care and legal compliance, making this choice incorrect.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

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

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: Reflecting the patient’s guilt and inviting further discussion is therapeutic, as it validates emotions and encourages exploration of feelings. This engages the patient’s emotional processing, fostering coping and reducing self-blame through empathetic communication, making this the correct choice.

Choice B reason: Telling the patient not to blame themselves dismisses their feelings, potentially inhibiting emotional expression. This nontherapeutic response fails to explore the patient’s guilt, which could stem from perceived control over their condition, making this choice incorrect.

Choice C reason: Advising to focus on the future minimizes the patient’s current emotional distress, a nontherapeutic approach. It overlooks the need to process guilt, which can affect diabetes management adherence, making this response less effective than exploring feelings.

Choice D reason: Downplaying diabetes as “not a big deal” invalidates the patient’s emotional experience, a nontherapeutic response. It fails to address guilt, which could impact psychological adjustment to the diagnosis, making this choice incorrect for therapeutic communication.

A. Maintaining limbs in a fixed position B. Repetitive, purposeless movements like rocking or pacing C. Rapid, involuntary muscle jerks or spasms D. Resistance to passive movement followed by a sudden release

Correct Answer is A

Explanation

Choice A reason: Waxy flexibility, seen in catatonia, involves patients maintaining limbs in fixed positions when placed there, reflecting basal ganglia and prefrontal cortex dysfunction. This passive rigidity is a hallmark of catatonic schizophrenia or mood disorders, making this the correct choice.

Choice B reason: Repetitive, purposeless movements like rocking are stereotypic behaviors, often in autism or anxiety disorders. These active movements differ from the passive, fixed posturing of waxy flexibility in catatonia, making this choice incorrect.

Choice C reason: Rapid, involuntary muscle jerks or spasms are extrapyramidal symptoms, often from antipsychotics affecting dopamine pathways. These are distinct from the sustained, passive limb positioning in waxy flexibility, making this choice incorrect for the described phenomenon.

Choice D reason: Resistance to passive movement followed by release describes cogwheel rigidity, seen in Parkinson’s disease, due to dopamine deficits. Waxy flexibility involves sustained positioning without resistance, making this choice incorrect for the catatonic feature described.

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 patient becomes agitated and physically aggressive on the unit, requiring the use of restraints. Which of the following actions by the nurse is appropriate when applying and managing restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient recently diagnosed with type 2 diabetes tells the nurse, “This is all my fault. If I had taken better care of myself, I wouldn’t be in this situation.” Which response by the nurse is the most therapeutic?

Correct Answer is A

Explanation

What is waxy flexibility in psychiatric patients?

Correct Answer is A

Explanation

The nurse is caring for a patient recently diagnosed with a terminal illness. The patient says, “There’s no way this is right. I’m going to get another opinion—this doctor doesn’t know what they’re talking about.” The nurse recognizes that the patient is in which stage of grief?

A patient recently lost her spouse and says, “I don’t know how I’m going to live without him.” Which of the following responses by the nurse is nontherapeutic?

Which of the following are examples of intentional torts in nursing practice? (Select all that apply)

A patient is brought to the psychiatric unit by family members after expressing suicidal thoughts but refuses voluntary admission. The healthcare team proceeds with involuntary commitment. Which of the following statements best describes involuntary commitment?

A client on a psychiatric unit states, “It’s a waste of time being here. I can’t talk to you or anyone.” Which is the correct nursing response?

A nurse observes a patient with bipolar disorder who suddenly shifts from laughing joyfully to crying within minutes during the therapy session. This sudden and intense change in emotional expression is an example of:

A patient diagnosed with schizophrenia tells the nurse, “I hear voices sometimes, but they don’t bother me.” Which of the following is the most appropriate open-ended response by the nurse to further assess the patient’s experience?