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. Diabetes mellitus is not a contraindication for methylergonovine, although blood glucose should be monitored in all postpartum clients.
B. Hypertension is a contraindication because methylergonovine causes vasoconstriction, which can dangerously elevate blood pressure and increase the risk of stroke or other cardiovascular complications.
C. Migraine headaches are not an absolute contraindication, although ergot derivatives can potentially exacerbate migraines in some clients.
D. Hepatitis B is not a contraindication, though liver function should be monitored when using medications metabolized by the liver.
Correct Answer is B
Explanation
A. 3hr oral glucose tolerance test - This test is typically used for diagnosing gestational diabetes or impaired glucose tolerance, not for long-term management.
B. HbA1c - Hemoglobin A1c reflects the average blood glucose levels over the past 2-3 months and is a reliable indicator of long-term glycemic control.
C. Fasting blood glucose test - This provides a snapshot of blood glucose levels at a specific point in time and is not as reliable for assessing long-term glycemic control as HbA1c.
D. Urinalysis for ketones - Urinalysis for ketones is useful for detecting acute complications such as diabetic ketoacidosis but does not reflect long-term management of blood glucose levels.
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