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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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Auditory hallucinations are more commonly associated with psychosis rather than a depressive episode.

B. Inability to carry out simple tasks is a hallmark of a depressive episode due to low energy, poor concentration, and feelings of hopelessness.

C. Moving quickly from one idea to the next (flight of ideas) is characteristic of a manic episode, not a depressive episode.

D. Illusions of grandeur occur during manic episodes, not depressive episodes.

A. Inform the client that using pharmacological pain management will not impact the delivery. B. Encourage the client to have the family exit the room when the pain is unbearable. C. Have the client exhale deeper than she inhales to promote adequate ventilation. D. Provide information about the use of hydrotherapy during labor.

Correct Answer is D

Explanation

A. Informing the client about pharmacological pain management contradicts her decision for a natural childbirth.

B. Encouraging family to leave during pain is unnecessary and may reduce support, which is essential for coping during labor.

C. Breathing techniques are helpful, but exhaling deeper than inhaling may not be appropriate for ventilation; rhythmic breathing is typically encouraged.

D. Hydrotherapy (such as warm baths or showers) is a natural pain management technique that can promote relaxation and decrease labor pain.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is caring for a client who is in the active phase of labor and has decided to have a natural childbirth. Which of the following pain management techniques should the nurse suggest?

Correct Answer is D

Explanation

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