A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?
Plan to monitor the client every 30 min while restrained.
Request a provider to evaluate the client in person every 36 hr.
Ensure that the prescription for restraints be renewed every 6 hr.
Document the client's behavior every 15 min.
The Correct Answer is D
A. Monitoring every 30 minutes is insufficient; it should be more frequent.
B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.
C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.
D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Confusion is a key symptom of hypoglycemia due to the brain's lack of glucose.
B. Acetone breath is associated with diabetic ketoacidosis (DKA), a hyperglycemic state.
C. Polydipsia (increased thirst) is a sign of hyperglycemia, not hypoglycemia.
D. Hot, dry skin is a sign of hyperglycemia or dehydration.
Correct Answer is B
Explanation
A. "I will monitor the client’s blood glucose level every 8 hours": Incorrect. Blood glucose should be monitored more frequently, typically every 4-6 hours, due to the risk of hyperglycemia.
B. "I will hang a new bag of TPN and IV tubing every 24 hours": This practice reduces the risk of infection associated with TPN, which is a high-risk therapy.
C. "I will increase the rate of the TPN infusion to ensure the correct amount is given": Incorrect. The TPN infusion rate should not be adjusted without a provider's order, as it can cause hyperglycemia or fluid overload.
D. "I will obtain the client’s weight every other day": Incorrect. Daily weights are necessary to monitor fluid status and nutritional effectiveness.
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