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 B

Explanation

A. A fundal height of 2 fingerbreadths below the umbilicus in a client who is 2 days postpartum is within the expected range for that time frame and does not require immediate assessment.

B. A client who is 1 day postpartum and has not voided in 8 hours may be at risk for urinary retention, which can lead to complications such as bladder distension or urinary tract infection. Prompt assessment and intervention are needed.

C. Not having a bowel movement since prior to admission is not an urgent concern in the

immediate postpartum period, especially if the client is otherwise stable and not experiencing discomfort or other symptoms.

D. Lochia serosa, which is the normal vaginal discharge that occurs 3 to 10 days postpartum, is not an urgent concern and does not require immediate assessment.

A. A series of four hepatitis vaccines is recommended to prevent viral hepatitis. B. Hepatitis B is transmitted by contaminated food. C. Chronic hepatitis can lead to renal cell cancer. D. Clients who have a history of viral hepatitis are unable to donate blood.

Correct Answer is D

Explanation

Choice A Rationale: The recommended hepatitis vaccine series does not consist of four vaccines. The Advisory Committee on Immunization Practices (ACIP) recommends a 3-dose series for most individuals, which includes doses at birth, 1-2 months, and 6-18 months.

Choice B Rationale: Hepatitis B is not typically transmitted by contaminated food. It is primarily spread through exposure to infectious blood, semen, and other body fluids. Transmission can occur through direct contact with blood or body fluids of an infected person, unprotected sex, sharing needles, or from mother to child at birth.

Choice C Rationale: While chronic hepatitis C has been associated with an increased risk of developing renal cell carcinoma, the evidence linking chronic hepatitis B with renal cell cancer is less clear. Some studies suggest a potential association, but it is not established as a common complication.

Choice D Rationale: Individuals with a history of hepatitis B or C are generally ineligible to donate blood. This is due to the risk of bloodborne transmission of these viruses. Even if the individual has recovered or been cured of hepatitis C, they are still barred from donating blood or plasma.

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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 B

Explanation

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Correct Answer is D

Explanation

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