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:

Prevents the breakdown of acetylcholine.

Galantamine is an acetylcholinesterase inhibitor, which means it works by preventing the breakdown of acetylcholine in the brain. Acetylcholine is a neurotransmitter that is important for memory and learning. By inhibiting the enzyme that breaks down acetylcholine, galantamine increases the levels of acetylcholine available in the brain, which can help improve cognitive function in patients with Alzheimer’s disease1. This mechanism of action is crucial because it directly addresses the cholinergic deficit observed in Alzheimer’s disease.

Choice B Reason:

Decreases amyloid plaques in the brain.

This statement is incorrect. Galantamine does not work by decreasing amyloid plaques in the brain. Amyloid plaques are one of the pathological hallmarks of Alzheimer’s disease, but galantamine’s primary mechanism of action is related to acetylcholine metabolism. Other treatments and research efforts focus on targeting amyloid plaques, but this is not the function of galantamine.

Choice C Reason:

Increases acetylcholine levels in the brain.

While this statement is partially correct, it is not as precise as the correct answer. Galantamine increases acetylcholine levels indirectly by preventing its breakdown rather than directly increasing its production. The distinction is important because the therapeutic approach involves inhibiting the enzyme acetylcholinesterase, which breaks down acetylcholine, thereby increasing its availability.

Choice D Reason:

Limits neurotransmitter engagement of NMDA receptors.

This statement is incorrect. Limiting neurotransmitter engagement of NMDA receptors is the mechanism of action for a different class of Alzheimer’s medications, such as memantine. Galantamine does not affect NMDA receptors; instead, it enhances cholinergic function by inhibiting acetylcholinesterase and potentiating nicotinic receptors.

A. Assess regularly for self-harm during treatment. B. Allow for unlimited discussion on physical symptoms. C. Discuss alternative coping strategies with the client. D. Encourage alone time for the client in seclusion.

Correct Answer is C

Explanation

Choice A Reason: Assess regularly for self-harm during treatment

Regular assessment for self-harm is crucial in any psychiatric care plan, especially for clients with conversion disorder who may experience significant distress. However, this action alone does not address the underlying issues or provide the client with tools to manage their symptoms. Continuous monitoring is important, but it should be part of a broader, more comprehensive care plan.

Choice B Reason: Allow for unlimited discussion on physical symptoms

While it is important to validate the client’s experiences and provide a space for them to discuss their symptoms, allowing unlimited discussion can sometimes reinforce the symptoms and lead to increased focus on physical complaints. This approach may not be beneficial in the long term and can detract from addressing the psychological aspects of the disorder.

Choice C Reason: Discuss alternative coping strategies with the client

This is the correct answer. Discussing alternative coping strategies helps the client develop skills to manage their symptoms more effectively. Techniques such as cognitive-behavioral therapy (CBT), relaxation exercises, and stress management can be very beneficial. These strategies empower the client to handle stress and reduce the impact of their symptoms. Providing education on coping mechanisms is a proactive approach that can lead to better outcomes.

Choice D Reason: Encourage alone time for the client in seclusion

Encouraging alone time in seclusion is generally not recommended for clients with conversion disorder. Seclusion can increase feelings of isolation and distress, potentially exacerbating symptoms. Instead, supportive and interactive interventions are preferred to help the client feel connected and understood.

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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 patient with mild Alzheimer’s disease is prescribed to take galantamine. Which statement best describes how this medication works to treat this disease?

Correct Answer is A

Explanation

A nurse is caring for a client who is diagnosed with Functional Neurologic Symptom Disorder (conversion disorder). What action should the nurse include in the plan of care?

Correct Answer is C

Explanation

A client is admitted to the inpatient psychiatric unit with a diagnosis of a somatoform disorder. Which statement does the nurse recognize as true about all somatoform disorders?

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