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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
Choice A Reason:
Use a calm voice.
Using a calm voice is essential in de-escalating an agitated client. A calm and steady tone can help soothe the client and reduce their anxiety. It also demonstrates that the nurse is in control of the situation and is there to help, which can be reassuring for the client.
Choice B Reason:
Speak louder than the client so as to be heard.
Speaking louder than the client is not appropriate as it can escalate the situation further. Raising one’s voice can be perceived as confrontational and may increase the client’s agitation. It is important to maintain a calm and composed demeanor to help de-escalate the situation.
Choice C Reason:
Reduce stimuli for the client.
Reducing stimuli is an effective intervention for an agitated client. Excessive noise, bright lights, and other environmental stimuli can exacerbate agitation. Creating a quieter and more controlled environment can help the client feel more at ease and reduce their agitation.
Choice D Reason:
Attempt to redirect the client.
Attempting to redirect the client can be helpful in de-escalating agitation. Redirecting the client’s attention to a different topic or activity can help distract them from the source of their agitation and provide a sense of control. This technique can be effective in calming the client and preventing further escalation.
Choice E Reason:
Reprimand the client for upsetting everyone.
Reprimanding the client is not an appropriate intervention. It can increase the client’s feelings of frustration and agitation. Instead, the focus should be on understanding the client’s needs and providing support to help them calm down.
Correct Answer is C
Explanation
Choice A Reason:
Labeling mild anxiety as pathologic and suggesting that it warrants postponing the test is not accurate. Mild anxiety is a normal response to stress and can actually be beneficial in certain situations. It helps to increase alertness and focus, which can improve performance on tasks such as taking a test. Pathologic anxiety, on the other hand, is excessive and persistent, interfering with daily functioning and requiring clinical intervention.
Choice B Reason:
The idea that mild anxiety may be transferred to classmates and result in generalized anxiety disorder is not supported by evidence. Anxiety is a personal experience and while it can be influenced by the environment, it is not something that can be directly transferred from one person to another. Generalized anxiety disorder is a chronic condition characterized by excessive worry about various aspects of life, and it develops due to a combination of genetic, environmental, and psychological factors.
Choice C Reason:
While severe anxiety can interfere with cognitive ability, mild anxiety typically does not. In fact, mild anxiety can enhance cognitive performance by increasing alertness and focus. It is only when anxiety becomes overwhelming that it starts to impair cognitive functions such as memory, attention, and problem-solving.
Choice D Reason:
Mild anxiety is conducive to concentration and problem-solving. This level of anxiety can act as a motivator, helping individuals to focus better and perform tasks more efficiently. The Yerkes-Dodson law suggests that there is an optimal level of arousal (including anxiety) that enhances performance. Too little arousal can lead to underperformance, while too much can cause performance to deteriorate.
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