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.

Answer and Explanation

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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Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:

Alcohol use disorder is a risk factor for suicide. Alcohol can increase impulsivity and decrease inhibitions, which can lead to suicidal behaviors.

Choice B rationale:

Being currently married is generally considered a protective factor against suicide, not a risk factor.

Choice C rationale:

Access to lethal means, such as guns in the home, is a significant risk factor for suicide.

Choice D rationale:

A family history of suicide, including a sibling history of suicide, is a risk factor for suicide.

Choice E rationale:

Terminal illnesses, such as liver cancer, can increase feelings of hopelessness and despair, which are risk factors for suicide.

A. Hypomagnesemia B. Hypokalemia. C. Muscle wasting. D. Lanugo.

Correct Answer is B

Explanation

Choice A rationale:

Hypomagnesemia is not a common finding in clients with bulimia nervosa.

Choice B rationale:

Hypokalemia is a common finding due to purging behaviors, such as self-induced vomiting or misuse of laxatives, which can lead to loss of potassium.

Choice C rationale:

Muscle wasting is more commonly associated with anorexia nervosa, not bulimia nervosa.

Choice D rationale:

Lanugo, or fine body hair, is also more commonly associated with anorexia nervosa, not bulimia nervosa.

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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?.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in a mental health clinic is collecting data from a client to determine the client's risk for suicide. Which of the following findings should the nurse identify as a risk factor for suicide? (Select all that apply.) .

Correct Answer is ["A","C","D","E"]

Explanation

A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?.

Correct Answer is B

Explanation

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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?.