A mental health nurse is planning care for a group of clients.
Which of the following clients should the nurse identify as having a contraindication for applying restraints?
A client who has Obsessive Compulsive Disorder (OCD) and insists on mopping the floor in the day room.
A client who has a personality disorder and tries to manipulate the staff to gain privileges.
A client who has Bulimia Nervosa and refuses to come to the dining room for meals.
A client who is just recovering from a benzodiazepine overdose.
The Correct Answer is D
Choice A rationale: A client with Obsessive Compulsive Disorder (OCD) who insists on mopping the floor in the day room does not pose a direct threat to themselves or others. OCD is characterized by obsessions (persistent, intrusive
thoughts) and compulsions (repetitive behaviors that the person feels compelled to perform). The act of mopping the floor could be a compulsion for this client. While it may be disruptive or unusual, it is not harmful. Therefore, restraints would not be appropriate in this situation.
Choice B rationale: A client with a personality disorder who tries to manipulate staff to gain privileges can be challenging to manage, but this behavior does not warrant the use of restraints. Personality disorders are characterized by enduring patterns of behavior, cognition, and inner experience that deviate from the expectations of the individual’s culture. These patterns are inflexible and pervasive across many personal and social situations.
While manipulation can be frustrating for staff, it is not a danger to the client or others, and other interventions should be used to manage this behavior.
Choice C rationale: A client with Bulimia Nervosa who refuses to come to the dining room for meals is exhibiting behavior related to their eating disorder, but this does not justify the use of restraints. Bulimia Nervosa is characterized by recurrent episodes of binge eating followed by compensatory behaviors such as vomiting, fasting, or excessive exercise. Refusal to eat in a communal setting like a dining room is not uncommon for individuals with eating disorders. This behavior should be addressed through therapeutic interventions, not restraints.
Choice D rationale: A client who is just recovering from a benzodiazepine overdose is the correct answer. Restraints are contraindicated for this client because they could cause physical harm. After a benzodiazepine overdose, the client may experience symptoms such as drowsiness, confusion, and impaired coordination. Restraints could increase the risk of injury, particularly if the client becomes agitated or tries to remove them. In addition, restraints could potentially interfere with medical treatment for the overdose.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["15"]
Explanation
Question: How many mL should the nurse administer per dose?
Step 1: 150 mg ÷ 50 mg
Step 2: 3 × 5 mL
Answer: 15 mL per dose.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale: The client’s magnesium level is 1.7 mg/dL, which is below the normal range of 1.8 to 2.4 mg/dL. Hypomagnesemia can cause neuromuscular irritability, muscle weakness, tremors, and even seizures or cardiac arrhythmias in severe cases.
It’s often associated with other electrolyte imbalances such as hypokalemia and hypocalcemia.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, malabsorption, or excessive losses from the gastrointestinal tract.
Choice B rationale: The client’s chloride level is 98 mmol/L, which falls within the normal range of 96 to 106 mmol/L. Chloride is an important electrolyte that helps maintain acid-base balance, fluid balance, and is a component of gastric juice as hydrochloric acid.
There’s no immediate concern regarding the client’s chloride level.
Choice C rationale: The client’s phosphate level is 2.5 mg/dL, which is below the normal range of 2.8 to 4.5 mg/dL. Hypophosphatemia can lead to muscle weakness, bone pain, mental changes, and potentially life-threatening complications such as respiratory failure and heart failure.
In the context of anorexia nervosa, hypophosphatemia is a common complication during refeeding due to shifts in electrolytes.
Choice D rationale: The client’s potassium level is 3.5 mmol/L, which is at the lower end of the normal range of 3.5 to
5.0 mmol/L. Hypokalemia can cause muscle weakness, cramps, arrhythmias, and in severe cases, it can be life- threatening.
In the context of anorexia nervosa, this could be due to inadequate dietary intake, excessive losses due to vomiting or laxative abuse, or shifts in electrolytes during refeeding.
In conclusion, the nurse should follow up on the client’s magnesium, phosphate, and potassium levels due to their potential implications on the client’s health, especially considering the client’s current health status and the process of refeeding.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.