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 D
Explanation
A. Breathing exercises involve inhaling through the nose and exhaling through the mouth for better oxygenation and relaxation.
B. Mindfulness focuses on being present and observing thoughts nonjudgmentally, not necessarily seeking advice from others.
C. Guided imagery involves imagining calming or peaceful scenarios, not stimulating ones.
D. Progressive muscle relaxation involves tensing and then relaxing muscle groups to relieve tension and promote relaxation.
Correct Answer is A
Explanation
A. The anterior fontanel remains open until about 12-18 months of age, which is expected for an 8-month-old infant.
B. The posterior fontanel usually closes by 2-3 months of age, so it should be closed by 8 months.
C. The anterior and posterior fontanels are different sizes, with the anterior being larger.
D. Molding is typically seen during birth and resolves within a few days.
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