A charge nurse making rounds observes that assistive personnel 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?
Review the chart for nonrestraint alternatives for agitation
Inform the unit manager
Speak with the AP about the incident
Remove the restraints from the client’s wrist
The Correct Answer is D
a. Review the chart for nonrestraint alternatives for agitation: While reviewing alternatives is important, the immediate concern is ensuring the safety and well-being of the client by removing the restraints.
b. Inform the unit manager: While it's important to inform the unit manager, the first action should be to address the immediate safety issue by removing the restraints.
c. Speak with the AP about the incident: While it's important to discuss the incident with the assistive personnel, the first priority is to remove the restraints to prevent harm to the client.
d. Remove the restraints from the client’s wrist: This is the correct action to take first to ensure the client's safety and prevent further harm. Afterward, the nurse can address the situation with the assistive personnel and review alternatives for managing the client's agitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. Anorexia nervosa is a complex psychiatric disorder, and the client would benefit from the expertise of a mental health counselor to address underlying psychological issues.
b. Nutritional therapy is crucial in the treatment of anorexia nervosa to address malnutrition and establish healthy eating habits.
c. While physical therapy may be necessary in some cases, it is not typically the primary focus of care for clients with anorexia nervosa.
d. A case manager may assist with coordinating care, but they may not have the specialized knowledge required to address the specific needs of a client with anorexia nervosa.
e. An occupational therapist focuses on helping clients perform activities of daily living and may not be directly involved in the treatment of anorexia nervosa unless there are specific functional limitations that need addressing.
Correct Answer is C
Explanation
a. Green tags are used for the "walking wounded" who will need medical care at some point after more critical injuries have been treated. This would not be appropriate for a client with full thickness burns on 72% of his body, as this condition is life-threatening and requires immediate attention.
b. Yellow tags are for those who require observation and possible later re-triage. Their condition is stable for the moment, and they are not in immediate danger of death. This client's condition, however, is too critical for a yellow tag.
c. Black tags are typically used for individuals who are deceased or expected to die imminently. The chances of survival for this patient are very minimal since the burn surface area is more than 50% with full thickness burns
d. Red tags are for those with severe injuries who require immediate treatment but have a chance of survival.
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