A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints?

The client follows the nurse's simple instructions.

The client apologizes for their aggressive behavior.

The client requests that the restraints be removed.

The client maintains eye contact while talking with the nurse.

Answer and Explanation

The Correct Answer is A

- Rationale for A: Following simple instructions indicates that the client is cooperative and may no longer pose a threat to themselves or others, which is a primary consideration for the removal of restraints. It shows the client's ability to understand and comply with directions, suggesting they are in a calmer state of mind. This behavioral change is a positive sign of regained control, making it safe to consider restraint removal.
- Rationale for B: While an apology may show remorse, it does not necessarily indicate that the client has calmed down or that they can safely interact without the restraints. Apologies can be driven by various motivations and do not reliably demonstrate a change in the risk of aggression.
- Rationale for C: A request to have restraints removed is not sufficient evidence of reduced risk. The client's desire to be unrestrained does not equate to a behavioral change that would justify removal, as it does not assess the client's current mental state or potential for aggression.
- Rationale for D: Maintaining eye contact is a positive social behavior but does not directly correlate with the client's potential for aggression or their ability to be safely managed without restraints. It is not a definitive indicator of the client's readiness to have restraints removed.

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Correct Answer is D

Explanation

A. Sputum culture is used to diagnose active tuberculosis but is not typically used for routine screening of asymptomatic individuals.

B. Chest x-ray can detect active tuberculosis or its complications but is not typically used for routine screening of asymptomatic individuals.

C. QuantiFERON-TB Gold blood analysis is a blood test that detects the presence of tuberculosis infection but is not typically used for routine screening of asymptomatic individuals.

D. The Mantoux test, also known as the tuberculin skin test (TST), is commonly used for routine screening of tuberculosis infection in asymptomatic individuals, including new employees in healthcare settings.

A. A child who has a forehead wound that is bleeding copiously B. A child who has a compound fracture of the femur and is crying in pain C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip

Correct Answer is C

Explanation

A. A child who has a forehead wound that is bleeding copiously: While bleeding wounds require attention, they are not immediately life-threatening compared to other injuries described.

B. A child who has a compound fracture of the femur and is crying in pain: While painful, a

femur fracture is not typically immediately life-threatening unless it is causing severe bleeding or compromising circulation.

C. A child who reports diplopia and nausea and was unconscious at the scene but is now awake:

These symptoms suggest potential head trauma and require urgent evaluation to assess for intracranial injuries.

D. A child who has several missing permanent teeth and a swollen, ecchymotic upper lip: These injuries, while concerning, are not immediately life-threatening compared to the potential head injury described in option C.

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A nurse in a mental health facility is evaluating the effectiveness of mechanical restraints for a client who threw a chair in the day room. The nurse should identify which of the following findings as an indication to remove the restraints?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reviewing the employee health program for new employees. Which of the following diagnostic assessments should the nurse recommend for all new employees to screen for the presence of tuberculosis?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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