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 A

Explanation

A. Troponin is a protein released into the bloodstream when there is damage to the heart muscle (myocardium), such as during a heart attack. Elevated troponin levels indicate myocardial injury or damage, making this the correct choice for indicating myocardial damage.

B. Erythrocyte sedimentation rate (ESR) measures the rate at which red blood cells settle in a tube of blood. It is a non-specific marker of inflammation and is not specific to myocardial damage.

C. Human B-type natriuretic peptide (BNP) is released by the heart in response to increased pressure and volume. Elevated levels are indicative of heart failure, not necessarily myocardial damage.

D. Activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot. It is used to monitor the effectiveness of anticoagulant therapy and is not specific to myocardial

damage.

A. The client is taking an antidepressant. B. The client has a history of a seizure disorder. C. The client takes aspirin daily. D. The client has a history of rheumatoid arthritis.

Correct Answer is C

Explanation

A. There is no known significant interaction between garlic supplements and antidepressants.

B. There is no evidence to suggest that garlic supplements are contraindicated for individuals with a history of seizure disorders. Garlic is not known to exacerbate seizure activity or interact with anticonvulsant medications.
C. Garlic has antiplatelet properties, which can increase the risk of bleeding, especially when combined with other blood-thinning agents like aspirin. Clients who take aspirin daily are at an increased risk of bleeding complications if they also take garlic supplements. This makes it a contraindication in such cases.
D. There are no known contraindications specifically related to rheumatoid arthritis and garlic supplements.

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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

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Correct Answer is A

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Correct Answer is C

Explanation

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