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.

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Correct Answer is A

Explanation

Choice A reason: Withdrawn behavior and avoiding eye contact suggest ineffective coping, as the patient struggles to process missing a treatment. Psychiatric evaluation can assess underlying emotional distress, such as anxiety or depression, and provide targeted interventions, making this the correct choice for addressing the patient’s needs.

Choice B reason: Symptoms like withdrawal could suggest depression, but diagnosing major depressive disorder requires more criteria, such as persistent low mood or anhedonia, not evident here. Immediate intervention assumes severity not supported by the scenario, making this choice less accurate than a referral.

Choice C reason: Labeling the patient as noncompliant assumes intentional refusal, but the scenario suggests emotional distress, not deliberate nonadherence. Withdrawal and avoidance indicate psychological barriers, not noncompliance, making this choice incorrect for the described behavior.

Choice D reason: Normal grief involves stages like denial or sadness, but the scenario lacks evidence of a loss triggering grief. Withdrawal and avoidance suggest coping difficulties, not a clear grief process, making this choice incorrect for the patient’s presentation.

A. Tangential thinking B. Circumstantial thinking C. Flight of ideas D. Concrete thinking

Correct Answer is A

Explanation

Choice A reason: Tangential thinking involves shifting topics without returning to the original point, common in schizophrenia or mania. It reflects disorganized thought processes due to impaired prefrontal cortex function, leading to irrelevant responses, making this the correct choice for the described speech pattern.

Choice B reason: Circumstantial thinking involves excessive detail but eventually returns to the original point. The scenario describes never returning to the question, indicating a more disorganized process than circumstantiality, making this choice incorrect for the patient’s speech pattern.

Choice C reason: Flight of ideas involves rapid topic shifts driven by associations, often in mania. While similar, it is less aimless than tangentiality, which does not return to the original topic, making this choice less precise for the described behavior.

Choice D reason: Concrete thinking involves literal interpretations without abstract reasoning, common in cognitive impairments. The scenario describes topic-shifting, not literal thinking, making this choice incorrect, as it does not address the disorganized speech pattern observed.

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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

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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