The nurse is reviewing documentation after restraints were used. What item from the documentation should be removed?

Interventions that were used prior to the use of restraint

Least-restrictive measures used prior to the use of restraint

The patient’s behavior that led to the use of restraint

The names of people the patient harmed during the violent episode

Answer and Explanation

The Correct Answer is D

A: Documenting interventions used prior to the use of restraint is necessary to show that all other options were exhausted before resorting to restraints.

B: Documenting least-restrictive measures used prior to the use of restraint is important to demonstrate that the least restrictive options were attempted first.

C: Documenting the patient’s behavior that led to the use of restraint is crucial for justifying the use of restraints and for future care planning.

D: The names of people the patient harmed during the violent episode should be removed to protect their privacy and confidentiality.

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Correct Answer is D

Explanation

Choice A:
This statement describes a behavior more closely associated with bulimia nervosa, where individuals engage in compensatory behaviors such as vomiting to prevent weight gain after overeating. Binge eating disorder (BED) does not involve regular purging behaviors.
Choice B:
This statement indicates a focus on healthy eating and calorie counting, which is not characteristic of binge eating disorder. BED involves episodes of eating large quantities of food with a sense of loss of control, not controlled eating habits.
Choice C:
This statement reflects weight loss and improved body image, which does not align with the symptoms of binge eating disorder. BED is characterized by recurrent episodes of eating large amounts of food and feeling a lack of control over eating.
Choice D:
This statement aligns with the diagnostic criteria for binge eating disorder. Individuals with BED often eat large amounts of food and feel uncomfortably full, accompanied by feelings of disgust or guilt. This behavior is a key indicator of BED, as it involves eating beyond the point of fullness and experiencing negative emotions afterward.

A. Determine if the medication can be switched to a difficult-to-conceal form (e.g., liquid, fast-dissolving tablet). B. Address underlying reasons for not wanting to take medications. C. Assess for delusions and hallucinations once a shift. D. Administer medications in a seclusion room so they can be closely monitored. E. Don’t allow the patient to attend group activities if medication was not taken.

Correct Answer is ["A","B"]

Explanation

A: Switching to a difficult-to-conceal form of medication can help ensure that the patient takes their medication as prescribed. Liquid or fast-dissolving tablets are harder to hide or spit out.

B: Addressing the underlying reasons for not wanting to take medications is crucial for understanding the patient’s perspective and finding solutions that encourage adherence.

C: While assessing for delusions and hallucinations is important, it is not directly related to ensuring medication adherence.

D: Administering medications in a seclusion room is not a standard practice and can be seen as punitive. It should only be used if the patient poses a risk to themselves or others.

E: Not allowing the patient to attend group activities if medication was not taken can be counterproductive and may increase the patient’s resistance to treatment.

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The nurse is reviewing documentation after restraints were used. What item from the documentation should be removed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing the patient’s dietary habits. Which statement by the patient most closely aligns with binge eating?

Correct Answer is D

Explanation

A patient with schizophrenia has been admitted to an inpatient facility. Since admission, the patient has been either refusing medication or cheeking their medications. What interventions should the nurse implement? Select all that apply.

Correct Answer is ["A","B"]

Explanation

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