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 D
Explanation
A. Brushing teeth immediately after eating may exacerbate nausea in some individuals. It is recommended to wait a while after eating before brushing teeth, or rinse the mouth with water.
B. Lying down after meals can worsen symptoms of nausea and reflux. Remaining upright or sitting up after meals may help alleviate symptoms.
C. Drinking large amounts of water with meals may exacerbate feelings of fullness and contribute to nausea. Sipping small amounts of fluids between meals is recommended.
D. Eating a dry carbohydrate, such as crackers or toast, before getting out of bed can help alleviate morning sickness by stabilizing blood sugar levels and absorbing stomach acid.
Correct Answer is A
Explanation
A.
A. Auscultating the client's left arm for a bruit helps assess the patency and function of the arteriovenous fistula. A bruit indicates normal blood flow through the fistula.
B. Comparing blood pressure in both arms every 2 hours is not specifically related to monitoring the arteriovenous fistula. Blood pressure comparison may be done periodically but is not as directly relevant to postoperative care of the fistula.
C. Instructing the client to keep the left arm in a dependent position may help with venous return but is not the primary action for monitoring the arteriovenous fistula's patency and function.
D. Encouraging the client to restrict movement of the left arm is not necessary unless there are specific instructions from the surgeon. Encouraging gentle movement and range of motion exercises may actually be beneficial for preventing stiffness and promoting healing.
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