Upon re-evaluation of the client, which of the following findings indicate that a change to the client's treatment plan is indicated?
The client says to the nurse in an authoritative voice, "Remove these restraints, I do not need them."
The client responds to the nurse's request and follows commands while being restrained.
The client asks the nurse to "Get my doctor on the phone, we need to talk about this situation."
The client tells another nurse that they are not a danger to themselves or others and to remove the restraints.
The Correct Answer is B
Choice A reason: A verbal demand to remove restraints does not necessarily indicate improved behavioral control. The client may still pose a risk to themselves or others, and authoritative speech alone is not sufficient evidence of stabilization.
Choice B reason: Following commands and responding appropriately while restrained indicates improved behavioral regulation and decreased risk of harm. This suggests that the client may no longer require restraints, and the treatment plan should be reassessed to avoid unnecessary restriction of autonomy. Restraints are meant to be temporary and discontinued once the client demonstrates self-control.
Choice C reason: Requesting to speak with the doctor shows insight and willingness to engage in care but does not directly demonstrate behavioral stability. The client may still be agitated or unsafe, so this finding alone does not justify changing the treatment plan.
Choice D reason: Stating that they are not a danger does not guarantee safety. Clients with mania or agitation may lack insight into their condition, and verbal reassurance cannot replace objective behavioral assessment.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Recording the client’s behavior every 15 minutes while in restraints is correct because frequent documentation ensures safety, monitors the client’s physical and psychological status, and provides evidence that restraints are being used appropriately.
Choice B reason: Securing restraints to the bed rail is unsafe because bed rails move and can cause injury. Restraints should be secured to the bed frame using a quick-release knot, not a slip knot, to allow rapid removal in emergencies.
Choice C reason: Raising all four bedrails is considered a restraint if it restricts the client’s freedom of movement. This statement is incorrect because it misrepresents restraint guidelines.
Choice D reason: Assessing a restrained client only once every 2 hours is insufficient. Clients must be assessed at least every 15 minutes for safety, circulation, and comfort. Two-hour checks would not meet safety standards.
Correct Answer is D
Explanation
Choice A reason: Asking how the client is feeling is supportive but does not address the immediate risk of harm. While therapeutic, it is not the priority in a crisis situation where safety must be assessed first.
Choice B reason: Offering to call someone for support is helpful but secondary. Before involving others, the nurse must determine if the client is at risk of self-harm.
Choice C reason: Asking about past coping strategies is useful for long-term support but does not address the immediate crisis. It assumes the client is safe, which must be confirmed first.
Choice D reason: Assessing for suicidal ideation is the priority because the client has experienced a traumatic loss and is showing signs of severe distress. The nurse must determine if the client is at risk of harming themselves before proceeding with other interventions. Ensuring safety is always the first priority in crisis care.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.