When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Documentation of the event will include interventions attempted prior to initiating restraints.

The physician must be present at the time of the restraint episode.

The client will be turned every 2 hours.

The client will need to be monitored every one-half hour.

Answer and Explanation

Correct Answer : A,C,D

Choice A Reason:

The statement “Documentation of the event will include interventions attempted prior to initiating restraints” is correct. Proper documentation is crucial when restraints are used. This includes detailing the client’s behavior that necessitated the restraint, the interventions attempted before applying the restraint, the type of restraint used, and the time it was applied. This documentation ensures transparency and accountability, and it helps in evaluating the necessity and appropriateness of the restraint use.

Choice B Reason:

The statement “The physician must be present at the time of the restraint episode” is incorrect. While a physician’s order is required for the use of restraints, the physician does not need to be physically present at the time of the restraint episode. However, the physician must evaluate the client within a specified time frame after the restraint is applied, typically within one hour. This ensures that the restraint is medically justified and that the client’s condition is appropriately monitored.

Choice C Reason:

The statement “The client will be turned every 2 hours” is correct. Clients in restraints must be regularly repositioned to prevent complications such as pressure ulcers and to ensure their comfort. Turning the client every 2 hours is a standard practice to maintain skin integrity and promote circulation. This intervention is part of the comprehensive care plan for clients in restraints.

Choice D Reason:

The statement “The client will need to be monitored every one-half hour” is correct. Frequent monitoring of clients in restraints is essential to ensure their safety and well-being. This includes checking for signs of distress, ensuring that the restraints are not causing harm, and assessing the client’s vital signs5. Monitoring every 30 minutes helps in promptly addressing any issues that may arise and ensures that the restraints are used safely and effectively.

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Correct Answer is A

Explanation

Choice A Reason:

Lorazepam is a benzodiazepine commonly used to manage acute agitation and anxiety. It works by enhancing the effect of the neurotransmitter GABA, which has a calming effect on the brain. Lorazepam is often administered in emergency situations to quickly reduce agitation and prevent escalation to violence. Its rapid onset of action makes it an ideal choice for managing acute episodes of agitation and potential assault.

Choice B Reason:

Valproic acid is an anticonvulsant and mood stabilizer used primarily for the treatment of epilepsy and bipolar disorder. While it can help manage mood swings and prevent manic episodes, it is not typically used for the immediate management of acute agitation or aggression. Its effects are not rapid enough to address an escalating situation effectively.

Choice C Reason:

Bupropion is an atypical antidepressant used to treat major depressive disorder and to support smoking cessation. It works by inhibiting the reuptake of norepinephrine and dopamine, but it does not have the sedative properties needed to manage acute agitation or aggression. Therefore, it is not suitable for immediate intervention in a potentially violent situation.

Choice D Reason:

Sertraline is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety disorders, and other mood disorders. While it is effective for long-term management of anxiety and depression, it does not have the rapid calming effects required for managing acute agitation or potential assault. SSRIs generally take several weeks to achieve their full therapeutic effect.

A. “It is okay to eat dessert with my dinner every night.” B. “I have less to worry about because I am a female.” C. “I can speak with my healthcare provider about genetic testing.” D. “I need to make sure to take my blood pressure medication daily.” E. “I do not have time in my schedule to add a daily walk.”

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

Explanation

Choice A Reason:

The statement “It is okay to eat dessert with my dinner every night” indicates a need for re-teaching. Diet plays a significant role in the risk of developing Alzheimer’s disease. Consuming high amounts of sugar and unhealthy fats can increase the risk of developing conditions like diabetes and cardiovascular disease, which are linked to a higher risk of Alzheimer’s. A balanced diet, such as the Mediterranean or MIND diet, which emphasizes fruits, vegetables, whole grains, and healthy fats, is recommended to reduce the risk.

Choice B Reason:

The statement “I have less to worry about because I am a female” is incorrect and indicates a need for re-teaching. In fact, women are at a higher risk of developing Alzheimer’s disease compared to men. This increased risk is partly due to women living longer than men, but even after accounting for longevity, women still have a higher incidence of Alzheimer’s. Therefore, it is crucial for females to be aware of their risk and take preventive measures.

Choice C Reason:

The statement “I can speak with my healthcare provider about genetic testing” does not indicate a need for re-teaching. Genetic testing can provide valuable information about one’s risk for Alzheimer’s disease, especially if there is a family history of the condition. While routine genetic testing is not generally recommended for everyone, discussing it with a healthcare provider can help individuals understand their risk and make informed decisions about their health.

Choice D Reason:

The statement “I need to make sure to take my blood pressure medication daily” is correct and does not indicate a need for re-teaching. Controlling blood pressure is crucial in reducing the risk of Alzheimer’s disease. High blood pressure, particularly in midlife, is a significant risk factor for cognitive decline and Alzheimer’s. Therefore, taking blood pressure medication as prescribed is an important preventive measure.

Choice E Reason:

The statement “I do not have time in my schedule to add a daily walk” indicates a need for re-teaching. Regular physical activity is one of the most effective ways to reduce the risk of Alzheimer’s disease. Exercise improves blood flow to the brain, reduces inflammation, and promotes the growth of new brain cells. Incorporating physical activity, such as a daily walk, into one’s routine is essential for maintaining cognitive health and reducing the risk of Alzheimer’s.

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When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse would expect to administer which of the following medications to a client who is escalating to the point of a possible assault?

Correct Answer is A

Explanation

A client was recently diagnosed with mild Alzheimer’s disease. Which of the statements shared by the client’s child about their risk for Alzheimer’s disease indicates the need for re-teaching? (Select all that apply.)

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

Explanation

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