A patient was placed in restraints after punching a staff member. Which statement by the patient requires the nurse’s immediate attention?

“I’m thirsty, give me a drink of water.”

“I punched him because he’s rude to us.”

“I’m going to report you because this is an illegal use of restraints.”

“If I say I’m sorry, would you let me out of here?”

Answer and Explanation

The Correct Answer is A

A: This statement requires immediate attention because it indicates a basic need that must be addressed to ensure the patient’s well-being while in restraints.

B: This statement reflects the patient’s justification for their behavior but does not require immediate attention.

C: This statement indicates the patient’s intention to report the use of restraints but does not require immediate attention.

D: This statement reflects the patient’s attempt to negotiate release from restraints but does not indicate an immediate need.

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Correct Answer is ["B","C"]

Explanation

A: Speaking loudly can escalate the patient’s agitation and is not recommended. A calm and soothing tone is more effective.

B: Ensuring adequate space between the nurse and the patient helps maintain safety and reduces the risk of physical harm.

C: Approaching the patient in a calm manner helps de-escalate the situation and provides reassurance to the patient.

D: Locking the patient in their room can increase their agitation and feelings of isolation. It should only be considered if the patient poses an immediate threat to themselves or others and other de-escalation techniques have failed.

E: Providing a detailed explanation of unit policies is not appropriate in the moment of crisis. The focus should be on immediate de-escalation and ensuring safety.

A. Impulsivity B. Emotional lability C. Reaction formation D. Splitting

Correct Answer is B

Explanation

A: Impulsivity refers to acting on urges without considering consequences, which is a feature of borderline personality disorder but not the best description of the scenario.
B: Emotional lability, or rapid and intense mood swings, accurately describes the client’s behavior in the scenario.
C: Reaction formation involves behaving in a way that is opposite to one’s true feelings, which is not depicted in the scenario.
D: Splitting involves viewing people or situations as all good or all bad, which can be a feature of borderline personality disorder but is not the primary feature shown in the scenario.

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A patient was placed in restraints after punching a staff member. Which statement by the patient requires the nurse’s immediate attention?

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Naxlex Comprehensive Predictor Exams

A patient who is experiencing auditory hallucinations has become increasingly agitated throughout the day. The patient suddenly kicks over an empty trash can and shouts “I WILL KILL YOU ALL!” at the wall. In response, the nurse should (Select all that apply).

Correct Answer is ["B","C"]

Explanation

Correct Answer is B

Explanation

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