A nurse is caring for a client who was placed in four-point restraints by the nursing staff following an episode of violent behavior.
Which of the following actions should the nurse take?.
Document the client's behavior in the medical record every 1 hr
Provide range-of-motion exercises to all extremities every 2 hr.
Request the provider renew the prescription in 24 hr.
Keep staff interactions with the client to a minimum.
The Correct Answer is B
Choice A rationale:
Documenting the client’s behavior every hour is not necessary. The nurse should monitor and document the client’s condition, but this does not need to be done every hour.
Choice B rationale:
Providing range-of-motion exercises to all extremities every 2 hours is important when a client is in restraints. This helps to prevent muscle stiffness and maintain circulation.
Choice C rationale:
The provider does not need to renew the prescription every 24 hours. The use of restraints should be reassessed regularly, but a new prescription is not required unless the restraints are removed and then need to be reapplied.
Choice D rationale:
Keeping staff interactions with the client to a minimum is not recommended. The client should be monitored closely and regular interaction can help to calm the client and reduce the need for restraints.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["The correct answers are choices: Approach client slowly"," \r\n Maintain a low stimulation environment"," \r\n and Reorient client to person"," \r\n place"," \r\n and time frequently. Approach client slowly rationale: This is a therapeutic intervention for clients who are confused and agitated. It can help to reduce anxiety and promote trust. Alternate nursing staff daily rationale: This is not recommended as it can lead to confusion and anxiety in the client. Consistency in care providers can help to promote trust and understanding. Maintain a low stimulation environment rationale: This can help to reduce agitation and confusion in the client. A calm and quiet environment can promote relaxation and understanding. Reorient client to person"," \r\n place"," \r\n and time frequently rationale: This is a therapeutic intervention for clients who are confused. It can help to promote reality orientation and reduce confusion. Provide the client with limited information about the diagnosis rationale: This is not recommended as it can lead to confusion and anxiety in the client. Clients have the right to be fully informed about their diagnosis and treatment."]
No explanation
Correct Answer is C
Explanation
Choice A rationale:
Phenobarbital is a barbiturate, not typically used in the treatment of opioid use disorder.
Choice B rationale:
Diazepam is a benzodiazepine, not typically used in the treatment of opioid use disorder.
Choice C rationale:
Buprenorphine is a medication approved for the treatment of opioid use disorder. It helps to reduce cravings and withdrawal symptoms.
Choice D rationale:
Chlordiazepoxide is a benzodiazepine, not typically used in the treatment of opioid use disorder.
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