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?
Request a provider to evaluate the client in person every 36 hr.
Document the client's behavior every 15 min.
Ensure that the prescription for restraints be renewed every 6 hr.
Plan to monitor the client every 30 min while restrained.
The Correct Answer is B
Choice A rationale:
Requesting a provider to evaluate the client in person every 36 hours might be necessary in certain situations but is not directly related to the management of a client in seclusion and restraints. It does not ensure the immediate safety and well-being of the client in this scenario.
Choice B rationale:
Documenting the client's behavior every 15 minutes is essential when a client is in seclusion and restraints. Regular and detailed documentation is crucial to monitor the client's response to the intervention, ensuring their safety, and providing necessary information for the healthcare team.
Choice C rationale:
Ensuring that the prescription for restraints be renewed every 6 hours is important to prevent unnecessary or prolonged use of restraints, but it doesn't address the immediate need for monitoring the client in seclusion and restraints.
Choice D rationale:
Monitoring the client every 30 minutes while restrained might not provide timely information, especially if the client's condition deteriorates rapidly. More frequent monitoring, such as every 15 minutes, allows for closer observation and quicker response to any changes in the client's status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.
Choice B rationale:
A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.
Choice C rationale:
Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.
Choice D rationale:
Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.
Correct Answer is A
Explanation
Choice A rationale:
Lavender oil is commonly used in aromatherapy and is known for its calming effects. However, it can trigger respiratory issues in individuals with asthma. Asthma is a chronic condition characterized by airway inflammation and bronchoconstriction, which can be exacerbated by inhaling certain substances, including strong odors and essential oils. Lavender oil, when inhaled, can potentially irritate the airways and worsen asthma symptoms. Therefore, a history of asthma is a contraindication for using lavender oil.
Choice B rationale:
Furosemide is a diuretic commonly used to treat fluid retention (edema) and hypertension. It works by increasing urine production and removing excess fluid from the body. Furosemide does not interact with lavender oil directly, and there is no known contraindication between these two substances.
Choice C rationale:
Alcohol use disorder is a condition characterized by an inability to control or stop alcohol consumption despite negative consequences. While alcohol abuse can have various health implications, it does not specifically interact with lavender oil in a way that constitutes a contraindication.
Choice D rationale:
Vitamin C is a water-soluble vitamin that plays a crucial role in various bodily functions, including immune system support and collagen synthesis. There is no evidence to suggest that taking vitamin C daily contraindicates the use of lavender oil. These two substances do not interact in a way that poses a risk to the individual.
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