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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
The correct answer is 2.5 mL. Calculation: Identify the desired dose: 50 mg Identify the available dose: 20 mg/mL Apply the formula: Desired ÷ Available = Volume to administer Calculation: 50 mg ÷ 20 mg/mL = 2.5 mL
Correct Answer is D
Explanation
Choice A rationale:
Alcohol can interfere with sleep patterns and should not be used as a sleep aid.
Choice B rationale:
Napping can make it harder to fall asleep at night.
Choice C rationale:
Eating just before bedtime can cause discomfort and disrupt sleep.
Choice D rationale:
Limiting caffeine intake can help improve sleep, as caffeine is a stimulant that can interfere with the ability to fall asleep.
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