An adult patient assaulted another patient and was then restrained. One hour later, which statement by the restrained patient requires the nurse's immediate attention?
"I hate all of you!"
"The other patient started the fight."
"You wait until I tell my lawyer."
"My fingers are tingly."
The Correct Answer is D
A. "I hate all of you!" –This reflects the patient’s anger and hostility, which is expected after being restrained. While it requires therapeutic communication, it does not signal a medical emergency.
B. "The other patient started the fight." – This statement is defensive and attempts to shift blame. Although it provides insight into the patient’s thought process, it is not urgent from a physiological standpoint.
C. "You wait until I tell my lawyer." – This reflects frustration and a threat of legal action. It is important for documentation and de-escalation but does not require immediate clinical intervention.
D. "My fingers are tingly." – This is the highest priority because it indicates impaired circulation or nerve compression related to the restraints. Tingling, numbness, coolness, or pallor are warning signs that restraints are too tight or causing neurovascular compromise. This can lead to permanent injury if not corrected promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Atomoxetine, a selective norepinephrine reuptake inhibitor (SNRI), can cause insomnia if taken late in the day; morning dosing reduces this risk.
B. Unlike some antipsychotics, atomoxetine is more commonly associated with appetite suppression and weight loss, not weight gain.
C. Atomoxetine is not a stimulant; it usually reduces hyperactivity and impulsivity.
D. Atomoxetine does not suppress the immune system; infection risk is not a concern.
Correct Answer is B
Explanation
A. Referring the patient to a minister avoids the nurse’s responsibility to provide immediate therapeutic support.
B. This response reflects the patient’s feelings and encourages further expression, which is therapeutic in depression.
C. Asking “why” can feel judgmental and place the patient on the defensive, which is non-therapeutic.
D. Giving false reassurance or imposing religious beliefs does not address the patient’s feelings and may shut down communication.
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