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. Diabetes insipidus does not cause hypoglycemia, so this is not relevant.
B. Capillary refill time is unrelated to diabetes insipidus management.
C. A heart rate of 140/min is tachycardic and may indicate dehydration or other complications, not medication effectiveness.
D. Desmopressin reduces excessive urine output, and a cessation of nocturnal enuresis (bedwetting) indicates improved fluid balance and medication effectiveness.
Correct Answer is ["A","B","C","D","E"]
Explanation
Easier to breathe and less short of breath: The client reports improvement in breathing, stating it is easier to breathe and they are less short of breath. This suggests that the respiratory status is improving, which is a key indicator of progress.
Lung sounds still diminished with crackles, but no wheezes detected: While lung sounds are still diminished and crackles remain, the absence of wheezes indicates that the client’s condition is stabilizing. Wheezing would be concerning for bronchospasm or worsening respiratory distress, so the absence of this finding is a positive development.
Oxygen saturation 92%: The client’s oxygen saturation has improved from 88% on room air (Day 1) to 92% on 1 L/min of oxygen. Although still slightly below the target of 94%–98%, this improvement is a sign that oxygenation is improving with the current treatment.
Pleuritic chest pain reduced to 3/10: The client's report of pleuritic chest pain has decreased from 6/10 to 3/10. This reduction in pain indicates a positive response to treatment and the improvement of the underlying infection.
Increased oral intake (drinking 2 L/day): The client is drinking 2 L of fluids per day, which indicates adequate hydration and may help with recovery, particularly in the context of respiratory and infection management.
Normal urine output (200 mL of clear yellow urine): The client’s urine output appears adequate, and the urine is clear and yellow, which suggests proper hydration and normal renal function, supporting overall recovery.
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