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 A
Explanation
The correct answer is choice A: "I anticipate that my child will feel some self-blame."
Choice A rationale: Recognizing that the adolescent may experience self-blame demonstrates understanding and empathy from the guardian. This statement suggests that the guardian is aware of potential emotional challenges the adolescent might face and can provide appropriate support.
Choice B rationale: While monitoring relationships may come from a place of concern, overly controlling behavior could potentially harm the adolescent's social development and trust in their support system.
Choice C rationale: Encouraging the adolescent to focus solely on the future might dismiss their current emotional state and the importance of processing their feelings. A positive support system should provide space for the adolescent to work through their emotions.
Choice D rationale: Encouraging the adolescent to think about what they did that allowed the event to happen can promote feelings of guilt and self-blame. This approach is not supportive and could exacerbate the adolescent's trauma.
Correct Answer is B
Explanation
Choice A rationale:
Using restraints can lead to injury and is generally a last resort.
Choice B rationale:
Placing a lock at the top of doors can prevent the client from wandering outside and getting lost or injured.
Choice C rationale:
Encouraging napping during the day can actually disrupt the client’s sleep cycle and increase nighttime wakefulness.
Choice D rationale:
While medication can be helpful, non-pharmacological interventions should be tried first.
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