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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "I should place a rolled blanket along each side of my baby's head in the car seat." - Incorrect. Placing rolled blankets on each side of the baby's head is not recommended as it can increase the risk of suffocation. Infants should be positioned in the car seat without any extra padding or blankets.
B. "I should place my baby's car seat rear-facing until 6 months of age." - Correct. Rear- facing car seats are recommended for infants until they reach at least 2 years of age or until they outgrow the weight and height limits specified by the car seat manufacturer. This position provides the best protection for the baby's head, neck, and spine in the event of a crash.
C. "I should put the car seat retainer clip at the level of my baby's belly button." - Incorrect. The retainer clip should be positioned at armpit level to secure the harness straps properly.
D. "I should position my baby's car seat at a 90-degree angle in the car." - Incorrect. Car seats should be installed at the appropriate recline angle according to the manufacturer's instructions, which may vary depending on the specific car seat model and the child's age and size.
Correct Answer is D
Explanation
A. Detaching the needle from the syringe before discarding it increases the risk of needle-stick injuries. Needles should be disposed of as one unit to minimize the risk of injury.
B. Broken glass should be disposed of in a puncture-proof container to prevent injuries. Placing it directly in a wastebasket increases the risk of puncture injuries to individuals handling the waste.
C. Recapping needles increases the risk of needle-stick injuries. Needles should not be recapped after use unless there is no safer alternative. Instead, they should be disposed of as one unit.
D. Lancets, needles, and other sharp objects should be placed in puncture-proof containers immediately after use to prevent injuries. This practice helps ensure the safety of healthcare workers and others who handle waste.
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