A charge nurse making rounds observes that an assistive personnel (AP) has applied wrist restraints to a client who is agitated and does not have a prescription for restraints. Which of the following actions should the nurse take first?
Inform the unit manager of the incident.
Speak with the AP about the incident.
Remove the restraints from the client's wrists.
Review the chart for nonrestraint alternatives for agitation,
The Correct Answer is C
A. Informing the unit manager is essential but not the first immediate action when a client is improperly restrained.
B. Speaking with the AP about the incident is important, but the priority is to ensure the client's safety and well-being.
C. Removing the restraints from the client's wrists is the first action to address the
inappropriate application of restraints without a prescription to ensure the client's safety and prevent harm.
D. Reviewing the chart for nonrestraint alternatives for agitation is important, but the priority is to address the immediate issue of the improperly applied restraints to the client.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Pertussis is a notifiable disease, meaning healthcare providers are required to report cases to the state health department for public health monitoring and intervention.
B. Rotavirus, though significant, may not be a reportable disease in all regions.
C. Group B streptococcal disease might require reporting in certain circumstances but typically isn't as universally notifiable as pertussis.
D. Respiratory syncytial virus might require reporting in specific situations, but pertussis typically has broader reporting requirements.
Correct Answer is D
Explanation
A. A generalized rash over the trunk might indicate various conditions but might not be an immediate concern in the context of meningitis.
B. An increased temperature is an expected finding in meningitis and should be
monitored but might not necessitate immediate reporting unless exceptionally high or coupled with other concerning symptoms.
C. Photophobia, or sensitivity to light, is a common symptom in meningitis but alone might not necessitate immediate reporting if the client's other symptoms are stable.
D. Decreased level of consciousness can indicate neurological deterioration and requires immediate attention as it could signal worsening of the client's condition.
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